Cost-effectiveness analysis of reacquiring and using adenovirus types 4 and 7 vaccines in naval recruits.

Adenovirus vaccines have controlled acute respiratory disease (ARD) in military recruits since 1971. Vaccine production, however, ceased and new facilities are required. We assessed whether reacquiring and using vaccines in naval recruits is cost-effective. Three policy options were evaluated: no vaccination, seasonal vaccination, and year-round vaccination. Morbidity (outpatient and inpatient), illness costs (medical and lost training), and vaccine program costs (start-up, acquisition, and distribution) were modeled using a decision-analytic method. Results were based on a cohort of 49,079 annual trainees, a winter vaccine-preventable ARD rate of 2.6 cases per 100 person-weeks, a summer incidence rate at 10% of the winter rate, a hospitalization rate of 7.6%, and a production facility costing US$12 million. Compared to no vaccination, seasonal vaccination prevented 4,015 cases and saved $2.8 million per year. Year-round vaccination prevented 4,555 cases and saved $2.6 million. Reacquiring and using adenovirus vaccines seasonally or year-round saves money and averts suffering.

Hepatitis B virus, human immunodeficiency virus type-1, and syphilis among women attending prenatal clinics in Belize, Central America.

Women and their infants may benefit from therapeutic interventions when hepatitis B, human immunodeficiency virus (HIV), or syphilis are detected during the prenatal period. We initiated hepatitis B and HIV screening of women attending prenatal clinics in Belize. Risk factor assessment information for hepatitis B infection and demographic data were determined by interview. Of 543 evaluable women, 81 (14.9%) were seropositive for hepatitis B core antibody (anti-HBc); one woman had asymptomatic hepatitis B surface antigenemia. Antibodies to HIV-1 were detected in one woman. Reactive syphilis serologies were detected in 15 (2.8%) women. Anti-HBc seroprevalence varied by district (range 3.1-43.5%) and by ethnicity (range 0.0-40.9%). Significant identified risks for anti-HBc seropositivity from univariate analyses included being of the Garifuna ethnic group, residence or birth in the Stann Creek or Toledo districts, a reactive syphilis serology, a household size of eight or greater, and five or more lifetime sexual partners. Multivariate analyses identified ethnicity and a reactive rapid plasma reagin as the best predictors of anti-HBc seropositivity. Highly variable differences in anti-HBc prevalence by district may permit the targeting of limited public health resources for education, screening, and prevention programs.

PIP: A cross-sectional study of 543 pregnant women attending prenatal clinics in Belize's 6 districts in a 6-week period in 1993 detected highly variable prevalences of hepatitis B virus (HBV) markers. 81 sera specimens (14.9%) were positive for anti-hepatitis B core antigen (anti-HBc); one woman had asymptomatic hepatitis B surface antigenemia. No HBV markers were detected in the sera of the 1 woman with human immunodeficiency virus (HIV)-1 infection. 15 women (2.8%) had reactive syphilis serologies. Serologic evidence of exposure to HBV was significantly associated with the following sociodemographic factors: single status, age 30-34 years, household size exceeding 8, 5 or more lifetime sexual partners, geographic location (residence in the Stann Creek or Toledo districts), and ethnicity (Garifuna, Creole, and Mayan). In the multivariate analysis, ethnicity and a reactive syphilis result were the only independent predictors of anti-HBc seroprevalence. Anti-HBc seroprevalence varied by district from 3.1-43.5%, with the highest rate in Stann Creek, and by ethnicity from 0 to 40.9%, with the highest rate among the Garifuna. Prevalences were substantially lower among Mestizo-Spanish from the northern and western districts of Orange Walk, Corozal, and Cayo. The overall low prevalence of HBsAg does not support a nationwide prenatal screening program, especially given limited public health care resources. However, this study's findings suggest the feasibility of HBV screening of pregnant women among the Garifuna, Creole, Mayan, and immigrant populations of Belize's Stann Creek and Toledo districts.

Point-of-entry screening for C. trachomatis In female army recruits. Who derives the cost savings?

BACKGROUND: Screening women for genital Chlamydia trachomatis at entry to military service provides an opportunity to reduce costs associated with sequelae of this infection. However, financial responsibility for screening may be debated. More than 50% of recruits return to civilian life within 2 years. The military and the civilian health care systems would both benefit from a screening program. OBJECTIVE: To assess the cost-effectiveness and relative cost savings to the military and civilian health sectors of three screening strategies for U.S. Army female recruits for C. trachomatis using urine ligase chain reaction: screening all recruits, screening recruits aged < or = 25 years, and no screening. METHODS: We applied a decision analytic model. Cost factors included screening, lost military training, morbid pelvic inflammatory disease, and other sequelae. Using a 5-year analytic horizon, we conducted analyses from military and civilian perspectives. RESULTS: Screening 10,000 female army recruits would cost 193,500 dollars and prevent 282 cases of sequelae, with a projected savings of 53,325 dollars to the military and 505,053 dollars to the civilian sector. From a military perspective, screening women aged < or = 25 years provided the highest cost savings. Screening all female recruits incurred an incremental cost of $1199 per sequela prevented. From a civilian perspective, screening all recruits offered the greatest cost savings. CONCLUSIONS: Screening female Army recruits for C. trachomatis offers substantial savings in health care costs for both the military and civilian health care systems. Relative financial benefit derived from recruit screening is disproportionate; greatest cost savings are enjoyed by the civilian sector.

Prevention of adenoviral acute respiratory disease in Army recruits: cost-effectiveness of a military vaccination policy.

INTRODUCTION: Since 1971 widespread vaccination has limited the number of adenoviral acute respiratory disease (ARD) outbreaks in Army recruits. Increased vaccine costs have recently threatened the continuation of the vaccination program. METHODS: We conducted a cost-effectiveness analysis to assess the consequences of changing the year-round Army adenovirus vaccination program to (1) seasonally targeted vaccine administration (only during the high-risk period) or (2) complete discontinuation of the program from the perspective of total cost to the Army. Costs included vaccination costs and direct and indirect medical and military training costs. Health outcomes were estimated as the number of hospitalizations for ARD prevented. In the reference case, the incidence rate among unvaccinated and vaccinated individuals was 4.06 and 1.5 per 100 person weeks, respectively. Results are expressed for a cohort of 76,171 recruits. RESULTS: In the absence of adenoviral vaccination, a projected 12,370 cases of ARD hospitalization would occur, costing $26.4 million annually. A seasonally targeted program would prevent 7,800 cases of ARD and save $16.1 million over no vaccination. Year-round immunization would not prevent any additional cases but would save $15.5 million over no vaccination. Year-round vaccination would become the cost-effective strategy if ARD incidence during the low-risk months were to increase. CONCLUSION: Vaccination of Army recruits by any schedule was cost-saving due to the high level of prevented disease and averted hospitalizations. Even though a seasonally targeted program provided the greatest cost-savings, year-round vaccination must remain an option due to the potential for adenoviral ARD outbreaks in the low-risk period.

Initial report of a hepatitis investigation in rural Belize.

In spring 1991, Belizian health officials expressed concern about a possible hepatitis outbreak in a banana farming district. A study was designed to identify cases and to address the serological prevalence of hepatitis virus markers. Three populations were studied: (i) persons meeting a clinical case definition for hepatitis; (ii) designated banana workers; and (iii) people in a random sample of households in the community. Information was collected using questionnaires and sera were collected for laboratory testing. This report presents the preliminary results of a study conducted in June 1991. Among people who met the clinical case definition, 24% of 42 tested had immunoglobulin M antibody to hepatitis B virus (HBV) core antigen (anti-HBc IgM). In the worker and household survey populations, 284 and 280 people, respectively, were tested for anti-HBc IgM. In each group, 4% were positive. HBV surface antigen was found in 37% of 43 clinical cases, 18% of workers, and 13% of people in the household survey. Among the 3 study populations, the prevalence of HBV core antibody (anti-HBc) ranged from 73% to 81%. Almost all tested persons had evidence of prior hepatitis A virus infection. Evidence of prior infection with hepatitis viruses A and B was widespread, but an aetiology could not be established for most of the clinical cases. However, the prevalence of hepatitis B markers in this population was very high compared to other reports from the Caribbean.

A geographical information system technique for record-matching in a study of cancer deaths in welders.

Retrospective studies are frequently complicated by incomplete worker identifiers. We encountered this problem when evaluating the risk of cancer death in a welding cohort. We dealt with it by developing birth-date ranges for each welder with unknown birth dates and using geographical information system techniques in conjunction with last name, gender, and birth-date range to assign death certificates to welders on the basis of residential proximity to the worksite. Deaths for total malignant cancers and lung/tracheobronchial/pleural cancers among these welders were not significantly different from those in county, state, and US populations, using standardized mortality ratios. The ratios in our study subjects were consistent with ratios found in other published welder cohorts.

The need for a military public health laboratory symposium.

The Department of Defense Global Emerging Infections Surveillance and Response System has a mission to identify vulnerabilities in the military health system related to the occurrence of emerging infectious diseases. Public health laboratory (PHL) functions are critical to the detection and control of emerging infectious diseases and were assessed. Four important services were evaluated: (1) surveillance for antibiotic resistance, (2) laboratory-based infectious disease surveillance, (3) provision of diagnostic services for uncommon infections, and (4) specimen referral and information transfer within a defined PHL infrastructure. Initial assessments identified several shortcomings and a lack of information about PHL functions. Therefore, a PHL symposium was held in September 1999 to define the state of civilian and military PHL functions, identify problems and interventions, and encourage civilian-military networking. After the symposium, selected attendees met in two workshop groups. One addressed the first two functions; the other addressed the last two.

Adenovirus vaccines in the U.S. military.

Acute respiratory disease (ARD) due to adenoviruses caused significant morbidity in military training populations. Since 1971 ARD has been controlled by the use of live, enteric-coated, adenovirus (ADV) types 4 and 7 vaccines. This immunization program overcame significant problems in vaccine development. Due to a production delay, military training posts stopped ADV vaccine administration in spring 1994. The delivery of ADV vaccine resumed in late February 1995, but another production delay is anticipated. A generation of military medical people have not been exposed to the significant morbidity caused by adenoviruses and are unaware of the effectiveness of the ADV vaccine. ARD morbidity before ADV vaccines, the ADV vaccine development program, and current issues regarding the control of ARD due to adenoviruses in the military are discussed.

Control of workers' compensation claims and costs in the U.S. Army.

The Army Medical Department has been implementing initiatives to reduce workers' compensation claims and costs since 1983. After years of an upward trend, reductions in both costs and claims were reported for 1995 and 1996. To assess efforts at managing workers' medical care and compensation in the Army, we reviewed Department of Defense and Department of the Army documents and studied data on claims and costs. We found several programs that were launched to control claims and associated costs. None of these programs adequately addressed the absence of real-time financial incentives for reducing compensation costs, a lack of acceptable workers' compensation data collection and data management systems, and a lack of emphasis on medical case management. To sustain this trend of decreased costs and claims, the Army must focus on (1) incentives, (2) data management systems, and (3) a comprehensive plan for medically managing workers' compensation claims and costs.

An epidemiologic method for assessing the effectiveness of hearing conservation programs using audiometric data.

A hearing conservation program (HCP) must include audiometric monitoring. In keeping with this requirement, enormous bodies of audiometric data have been accumulated. However, only a limited number of methods are available for using audiometric data to assess HCP effectiveness. This study illustrates an epidemiologic method. The risk of developing hearing loss (measured by the standard threshold shift) was compared between study and reference populations using the risk ratio. The study population had an increased risk of nearly 3-fold. Epidemiologic risk comparison methods, using reference populations, offer an alternative to current methods for HCP evaluation using audiometric data.

The role of military medicine in military civic action.

We are moving into an era when U.S. military forces will be called upon frequently to perform military civic action (MCA) projects. Such projects, have been used successfully and unsuccessfully, primarily in the areas of medicine and engineering, to enhance the standing of military forces with indigenous populations. However, the available criteria for planning and assessing MCA projects are not widely known. These related and overlapping criteria are supported by facts, interpretative data, anecdotes, and common sense, but none can be considered absolute. Selected criteria are defined, reviewed, and illustrated with examples of past successes and failures.

Tuberculosis and HIV infection in new inmates in Federal Bureau of Prisons facilities.

A significant change in the manner in which medical data were managed in the Federal Bureau of Prisons (BOP) occurred in calendar year 1992 (CY 92). Prior to CY 92, all BOP medical data were stored only as hard copy medical records. Beginning with CY 92, medical records data for all inmates have been transcribed to magnetic tape using the BOP SENTRY system. This study was an initial attempt to determine if this innovation would permit the development of meaningful infectious diseases data on BOP inmates. Our objective was to define the prevalence of tuberculosis (TB) skin test positivity, active TB, and HIV infection in new BOP inmates in CY 92 and to compare the new inmate population with the total BOP 1992 prisoner population. This initial study is important for two reasons: (1) the BOP SENTRY system for demographic and medical data was found to be a feasible tool for disease surveillance purposes; and (2) the 1992 new inmate population had much greater prevalences of purified protein derivative positivity, active TB, and HIV infection compared to the total BOP population. These findings may signal an increase in serious infectious diseases in BOP prisoners.

The Department of Defense laboratory-based global influenza surveillance system.

Military global influenza surveillance began in 1976 as an Air Force program. In 1997, the Department of Defense (DoD) Global Emerging Infections Surveillance and Response System expanded the program to include all services. Also included were local residents in areas where DoD overseas research activities operated. This new, worldwide DoD surveillance infrastructure provides valuable information and can respond quickly to outbreaks. This was demonstrated during the current influenza season when a suspected outbreak was reported in Panama. In less than 3 weeks, specimens were collected, transported, and cultured, and isolates were subtyped and sent to the Centers for Disease Control and Prevention for further studies. This influenza surveillance initiative combines viral isolation, antigenic characterization, and molecular sequencing with clinical and public health management of information. The information obtained is shared with the Centers for Disease Control and Prevention and the World Health Organization and has contributed to important decisions in influenza vaccine composition.