Burden of varicella complications in secondary care, England, 2004 to 2017.

BackgroundStrategies to control varicella vary across Europe. Evidence from established programmes has prompted the United Kingdom to re-evaluate the need for universal vaccination. The burden of complicated varicella is a key parameter in the cost-effectiveness analysis.AimOur objective was to estimate the burden of complicated varicella in England.MethodsThis electronic health record surveillance study used data from all NHS hospitals in England to identify varicella admissions between 2004 and 2017. The incidence of pre-defined complications of varicella was estimated using ICD-10 codes. Inpatient costs were calculated based on the payment rules for providers of NHS services.ResultsThere were 61,024 admissions with varicella between 2004 and 2017 and 38.1% had a recognised varicella complication. Incidence of hospitalisation increased by 25% and the proportion with complicated varicella by 24% from 2004/05 to 2016/17. The most common complications were bacterial skin infections (11.25%), pneumonia (4.82%), febrile convulsions (3.39%) and encephalitis (2.44%). Complication rates were higher in older age groups and the type of complications more severe. Length of stay for complicated varicella was 3.1 times longer than for uncomplicated varicella and inpatient costs were 72% greater.ConclusionComplicated varicella has a substantial health and economic burden. These data together with data on impact on quality of life are important in informing the cost-effectiveness analysis of universal varicella vaccination.

Impact and Cost-effectiveness of Selective Human Papillomavirus Vaccination of Men Who Have Sex With Men.

Background: Men who have sex with men (MSM) have a high lifetime risk of anogenital warts and cancers related to infection with human papillomavirus (HPV). They also benefit less from herd protection than heterosexual males in settings with female-only HPV vaccination. Methods: We evaluated the potential health impact and cost-effectiveness of offering vaccination to MSM who visit genitourinary medicine (GUM) clinics. We used a mathematical model of HPV 6/11/16/18 sexual transmission within an MSM population in England, parameterized with sexual behaviour, GUM attendance, HPV prevalence, HIV prevalence, warts, and cancer incidence data. Interventions considered were offering HPV vaccination to either HIV-positive MSM or MSM regardless of HIV status, for age bands 16-25, 16-30, 16-35, and 16-40 years. Results: Substantial declines in anogenital warts and male HPV-related cancer incidence are projected to occur following an offer of vaccination to MSM. MSM not attending GUM clinics will partially benefit from herd protection. Offering vaccination to HIV-positive MSM up to age 40 is likely to be cost-effective if vaccine procurement and administration costs are below £96.50 a dose. At £48 a dose, offering vaccination to all MSM up to age 40 is likely to be cost-effective. Conclusions: Quadrivalent HPV vaccination of MSM via GUM clinics is likely to be an effective and cost-effective way of reducing the burden of HPV-related disease in MSM.

Mixtures as a fungicide resistance management tactic.

We have reviewed the experimental and modeling evidence on the use of mixtures of fungicides of differing modes of action as a resistance management tactic. The evidence supports the following conclusions. 1. Adding a mixing partner to a fungicide that is at-risk of resistance (without lowering the dose of the at-risk fungicide) reduces the rate of selection for fungicide resistance. This holds for the use of mixing partner fungicides that have either multi-site or single-site modes of action. The resulting predicted increase in the effective life of the at-risk fungicide can be large enough to be of practical relevance. The more effective the mixing partner (due to inherent activity and/or dose), the larger the reduction in selection and the larger the increase in effective life of the at-risk fungicide. 2. Adding a mixing partner while lowering the dose of the at-risk fungicide reduces the selection for fungicide resistance, without compromising effective disease control. The very few studies existing suggest that the reduction in selection is more sensitive to lowering the dose of the at-risk fungicide than to increasing the dose of the mixing partner. 3. Although there are very few studies, the existing evidence suggests that mixing two at-risk fungicides is also a useful resistance management tactic. The aspects that have received too little attention to draw generic conclusions about the effectiveness of fungicide mixtures as resistance management strategies are as follows: (i) the relative effect of the dose of the two mixing partners on selection for fungicide resistance, (ii) the effect of mixing on the effective life of a fungicide (the time from introduction of the fungicide mode of action to the time point where the fungicide can no longer maintain effective disease control), (iii) polygenically determined resistance, (iv) mixtures of two at-risk fungicides, (v) the emergence phase of resistance evolution and the effects of mixtures during this phase, and (vi) monocyclic diseases and nonfoliar diseases. The lack of studies on these aspects of mixture use of fungicides should be a warning against overinterpreting the findings in this review.

The optimisation of Salmonella surveillance programmes for pullet and layer farms using local farm density as a risk factor.

Human salmonellosis cases are often caused by Salmonella serovars Enteritidis and Typhimurium and associated with the consumption of eggs and egg products. Many countries therefore implemented general surveillance programmes on pullet and layer farms. The identification of risk factors for Salmonella infection may be used to improve the performance of these surveillance programmes. The aims of this study were therefore to determine 1) whether local farm density is a risk factor for the infection of pullet and layer farms by Salmonella Enteritidis and Typhimurium and 2) whether the sampling effort of surveillance programmes can be reduced by accounting for this risk factor, while still providing sufficient control of these serovars. We assessed the importance of local farm density as a risk factor by fitting transmission kernels to Israeli surveillance data during the period from June 2017 to April 2019. The analysis shows that the risk of infection by serovars Enteritidis and Typhimurium significantly increased if infected farms were present within a radius of approximately 4 km and 0.3 km, respectively. We subsequently optimized a surveillance programme that subdivided layer farms into low and high risk groups based on the local farm density with and allowed the sampling frequency to vary between these groups. In this design, the pullet farms were always sampled one week prior to pullet distribution. Our analysis shows that the risk-based surveillance programme is able to keep the between-farm R0 of serovars Enteritidis and Typhimurium below 1 for all pullet and layer farms, while reducing the sampling effort by 32% compared to the currently implemented surveillance programme in Israel. The results of our study therefore indicate that local farm density is an important risk factor for infection of pullet and layer farms by Salmonella Enteritidis and Typhimurium and can be used to improve the performance of surveillance programmes.

Estimating the introduction time of highly pathogenic avian influenza into poultry flocks.

The estimation of farm-specific time windows for the introduction of highly-pathogenic avian influenza (HPAI) virus can be used to increase the efficiency of disease control measures such as contact tracing and may help to identify risk factors for virus introduction. The aims of this research are to (1) develop and test an accurate approach for estimating farm-specific virus introduction windows and (2) evaluate this approach by applying it to 11 outbreaks of HPAI (H5N8) on Dutch commercial poultry farms during the years 2014 and 2016. We used a stochastic simulation model with susceptible, infectious and recovered/removed disease stages to generate distributions for the period from virus introduction to detection. The model was parameterized using data from the literature, except for the within-flock transmission rate, which was estimated from disease-induced mortality data using two newly developed methods that describe HPAI outbreaks using either a deterministic model (A) or a stochastic approach (B). Model testing using simulated outbreaks showed that both method A and B performed well. Application to field data showed that method A could be successfully applied to 8 out of 11 HPAI H5N8 outbreaks and is the most generally applicable one, when data on disease-induced mortality is scarce.

Do high levels of diffuse and chronic metal pollution in sediments of Rhine and Meuse floodplains affect structure and functioning of terrestrial ecosystems?

This paper (re)considers the question if chronic and diffuse heavy metal pollution (cadmium, copper, lead and zinc) affects the structure and functioning of terrestrial ecosystems of Biesbosch National Park, the floodplain area of rivers Meuse and Rhine. To reach this aim, we integrated the results of three projects on: 1. the origin, transfer and effects of heavy metals in a soil-plant-snail food chain; 2. the impact of bioavailability on effects of heavy metals on the structure and functioning of detritivorous communities; 3. the risk assessment of heavy metals for an herbivorous and a carnivorous small mammal food chain. Metal pollution levels of the Biesbosch floodplain soils are high. The bioavailability of metals in the soils is low, causing low metal levels in plant leaves. Despite this, metal concentrations in soil dwelling detritivores and in land snails at polluted locations are elevated in comparison to animals from 'non-polluted' reference sites. However, no adverse effects on ecosystem structure (species richness, density, biomass) and functioning (litter decomposition, leaf consumption, reproduction) have been found. Sediment metal pollution may pose a risk to the carnivorous small mammal food chain, in which earthworms with elevated metal concentrations are eaten by the common shrew. Additional measurements near an active metal smelter, however, show reduced leaf consumption rates and reduced reproduction by terrestrial snails, reflecting elevated metal bioavailability at this site. Since future management may also comprise reintroduction of tidal action in the Biesbosch area, changes in metal bioavailability, and as a consequence future ecosystem effects, cannot be excluded.

Metal accumulation in the earthworm Lumbricus rubellus. Model predictions compared to field data.

The mechanistic bioaccumulation model OMEGA (Optimal Modeling for Ecotoxicological Applications) is used to estimate accumulation of zinc (Zn), copper (Cu), cadmium (Cd) and lead (Pb) in the earthworm Lumbricus rubellus. Our validation to field accumulation data shows that the model accurately predicts internal cadmium concentrations. In addition, our results show that internal metal concentrations in the earthworm are less than linearly (slope<1) related to the total concentration in soil, while risk assessment procedures often assume the biota-soil accumulation factor (BSAF) to be constant. Although predicted internal concentrations of all metals are generally within a factor 5 compared to field data, incorporation of regulation in the model is necessary to improve predictability of the essential metals such as zinc and copper.

The burden of hospitalisation for varicella and herpes zoster in England from 2004 to 2013.

OBJECTIVES: We aimed to determine the hospital burden of varicella-zoster virus infection (VZV) in England during 2004-2013 to support a future cost-effectiveness analysis of a childhood varicella vaccination programme. METHODS: We analysed the incidence, duration, outcome and costs of hospitalisations for VZV using the Hospital Episode Statistics (HES) database for the general and immunocompetent population. Mortality in HES was validated using data from the Office for National Statistics (ONS). RESULTS: The average annual incidences of admissions due to varicella and herpes zoster were 7.6 (7.3-7.9) and 8.8 (8.6-9.0) per 100,000, respectively. The immunocompetent population accounted for 93% and 82% of the admissions due to varicella and herpes zoster, respectively. The average yearly number of hospital days was 10,748 (10,227-11,234) for varicella and 41,780 (40,257-43,287) for herpes zoster. The average yearly hospital costs (£2013/14) were £6.8 million (6.4-7.2) for varicella and £13.0 million (12.8-13.4) for herpes zoster. The average annual numbers of deaths identified in HES due to varicella and herpes zoster were 18.5 (14.3-22.8) and 160 (147-172), respectively. Comparison with ONS mortality data indicated a high level of uncertainty. CONCLUSIONS: Most of the hospital burden due to VZV-virus in England occurs in the immunocompetent population and is potentially vaccine-preventable.

The emergence of resistance to fungicides.

Many studies exist about the selection phase of fungicide resistance evolution, where a resistant strain is present in a pathogen population and is differentially selected for by the application of fungicides. The emergence phase of the evolution of fungicide resistance--where the resistant strain is not present in the population and has to arise through mutation and subsequently invade the population--has not been studied to date. Here, we derive a model which describes the emergence of resistance in pathogen populations of crops. There are several important examples where a single mutation, affecting binding of a fungicide with the target protein, shifts the sensitivity phenotype of the resistant strain to such an extent that it cannot be controlled effectively ('qualitative' or 'single-step' resistance). The model was parameterized for this scenario for Mycosphaerella graminicola on winter wheat and used to evaluate the effect of fungicide dose rate on the time to emergence of resistance for a range of mutation probabilities, fitness costs of resistance and sensitivity levels of the resistant strain. We also evaluated the usefulness of mixing two fungicides of differing modes of action for delaying the emergence of resistance. The results suggest that it is unlikely that a resistant strain will already have emerged when a fungicide with a new mode of action is introduced. Hence, 'anti-emergence' strategies should be identified and implemented. For all simulated scenarios, the median emergence time of a resistant strain was affected little by changing the dose rate applied, within the range of doses typically used on commercial crops. Mixing a single-site acting fungicide with a multi-site acting fungicide delayed the emergence of resistance to the single-site component. Combining the findings with previous work on the selection phase will enable us to develop more efficient anti-resistance strategies.

Modeling future conservation of Hawaiian honeycreepers by mosquito management and translocation of disease-tolerant Amakihi.

Avian malaria is an important cause of the decline of endemic Hawaiian honeycreepers. Because of the complexity of this disease system we used a computer model of avian malaria in forest birds to evaluate how two proposed conservation strategies: 1) reduction of habitat for mosquito larvae and 2) establishment of a low-elevation, malaria-tolerant honeycreeper (Hawaii Amakihi) to mid-elevation forests would affect native Hawaiian honeycreeper populations. We evaluated these approaches in mid-elevation forests, where malaria transmission is seasonal and control strategies are more likely to work. Our model suggests the potential benefit of larval habitat reduction depends on the level of malaria transmission, abundance of larval cavities, and the ability to substantially reduce these cavities. Permanent reduction in larval habitat of >80% may be needed to control abundance of infectious mosquitoes and benefit bird populations. Establishment of malaria-tolerant Amakihi in mid-elevation forests increases Amakihi abundance, creates a larger disease reservoir, and increases the abundance of infectious mosquitoes which may negatively impact other honeycreepers. For mid-elevation sites where bird populations are severely affected by avian malaria, malaria-tolerant Amakihi had little impact on other honeycreepers. Both management strategies may benefit native Hawaiian honeycreepers, but benefits depend on specific forest characteristics, the amount of reduction in larval habitat that can be achieved, and how malaria transmission is affected by temperature.