Health and Economic Consequences of Lead Exposure Associated with Products and Services Provided by the Informal Economy.

In low- and middle-income countries (LMICs), the presence of an informal economy can lead to human exposure to toxic metals such as lead (Pb). This paper demonstrates the local health and economic benefits of modifying practices within the informal economic sector in Madagascar. Specifically, leaded components in 504 locally manufactured household water pumps were replaced with unleaded components. Prior to the intervention, 32% of the household systems exhibited lead concentrations above the World Health Organization (WHO) provisional drinking water guideline of 10 µg/L, but after the intervention, fewer than 3% of the systems were in exceedance. The reduction of lead concentration is modeled to reduce the fraction of children with elevated BLLs (>5 µg/dL) from 34 to 13%. The reduction in BLLs is estimated to provide an average economic benefit of US$11 800 per child based on predicted increases in lifetime productivity. This corresponds to a total benefit of US$8.7 million for the 730 children aged 1-5 associated with the pumps, representing a return on investment of greater than 1000-to-1. Results demonstrate how the formation of partnerships between public, private, and civil society entities, as suggested by UN Sustainable Development Goal 17, can realize important local economic and health benefits in LMICs.

Trans-arterial radioembolization for intermediate-advanced hepatocellular carcinoma: a budget impact analysis.

BACKGROUND: Trans-arterial radio-embolization (TARE) is an emerging treatment for the management of hepatocellular carcinoma (HCC). TARE may compete with systemic chemotherapy, sorafenib, in intermediate stage patients with prior chemoembolization failure or advanced patients with tumoral macrovascular invasion with no extra-hepatic spread and good liver function. We performed a budget impact analysis (BIA) evaluating the expected changes in the expenditure for the Italian Healthcare Service within scenarios of increased utilization of TARE in place of sorafenib over the next five years. METHODS: Starting from patient level data from three oncology centres in Italy, a Markov model was developed to project on a lifetime horizon survivals and costs associated to matched cohorts of intermediate-advanced HCC patients treated with TARE or sorafenib. The initial model has been integrated with epidemiological data to perform a BIA comparing the current scenario with 20 and 80% utilization rates for TARE and sorafenib, respectively, with increasing utilization rates of TARE of 30, 40 and 50% over the next 1, 3 and 5 years. RESULTS: Compared to the current scenario, progressively increasing utilization rates of TARE over sorafenib in the next 5 years is expected to save globally about 7 million Euros. CONCLUSIONS: Radioembolization can be considered a valuable treatment option for patients with intermediate-advanced HCC. These findings enrich the evidence about the economic sustainability of TARE in comparison to standard systemic chemotherapy within the context of a national healthcare service.

Real-World Data for the Evaluation of Transarterial Radioembolization versus Sorafenib in Hepatocellular Carcinoma: A Cost-Effectiveness Analysis.

OBJECTIVES: To perform a cost-effectiveness analysis comparing the use of transarterial radioembolization (TARE) with that of sorafenib in the treatment of patients with intermediate or advanced hepatocellular carcinoma (HCC) according to the Barcelona Clinic Liver Cancer staging system. METHODS: Patient-level data were consecutively recorded and collected at three oncology centers in Italy. A propensity score matching was performed to compare patients with similar clinical characteristics who underwent TARE or sorafenib treatment. Clinical data from the matched cohorts were used to populate a Markov model to project, on a lifetime horizon, life years, quality-adjusted life years, and economic outcomes associated with TARE and sorafenib for both intermediate and advanced HCC stages. RESULTS: Starting from data covering 389 and 241 patients who underwent TARE and sorafenib treatment, respectively, the propensity score matching yielded a total of 308 matched patients. For intermediate-stage patients, the model estimated for TARE versus sorafenib an incremental cost-utility ratio of €3,302/QALY (incremental cost-effectiveness ratio of €1,865 per life year gained), whereas for patients in advanced stage TARE dominated (lower costs and greater health improvements) compared with sorafenib. CONCLUSIONS: From an Italian health care service perspective, TARE could be a cost-effective strategy in comparison with sorafenib for patients with intermediate or advanced HCC. The results from forthcoming randomized controlled trials comparing TARE with sorafenib will be able to confirm or reject the validity of this preliminary evaluation. In the meantime, decision makers can use these results to control and coordinate the diffusion of the technology.

Non-communicable diseases: mapping research funding organisations, funding mechanisms and research practices in Italy and Germany.

BACKGROUND: Evidence shows that territorial borders continue to have an impact on research collaboration in Europe. Knowledge of national research structural contexts is therefore crucial to the promotion of Europe-wide policies for research funding. Nevertheless, studies assessing and comparing research systems remain scarce. This paper aims to further the knowledge on national research landscapes in Europe, focusing on non-communicable disease (NCD) research in Italy and Germany. METHODS: To capture the architecture of country-specific research funding systems, a three-fold strategy was adopted. First, a literature review was conducted to determine a list of key public, voluntary/private non-profit and commercial research funding organisations (RFOs). Second, an electronic survey was administered qualifying RFOs. Finally, survey results were integrated with semi-structured interviews with key opinion leaders in NCD research. Three major dimensions of interest were investigated - funding mechanisms, funding patterns and expectations regarding outputs. RESULTS: The number of RFOs in Italy is four times larger than that in Germany and the Italian research system has more project funding instruments than the German system. Regarding the funding patterns towards NCD areas, in both countries, respiratory disease research resulted as the lowest funded, whereas cancer research was the target of most funding streams. The most reported expected outputs of funded research activity were scholarly publication of articles and reports. CONCLUSIONS: This cross-country comparison on the Italian and German research funding structures revealed substantial differences between the two systems. The current system is prone to duplicated research efforts, popular funding for some diseases and intransparency of research results. Future research will require addressing the need for better coordination of research funding efforts, even more so if European research efforts are to play a greater role.

Integrated analysis of online signals and insight generation about digital conversations on COVID-19 vaccines in Eastern and Southern Africa: a longitudinal analysis of social listening data.

BACKGROUND: During the COVID-19 pandemic, social listening programs across digital channels have become an integral part of health preparedness and response planning, allowing to capture and address questions, information needs, and misinformation shared by users. This study identifies key social listening trends around COVID-19 vaccines in Eastern and Southern Africa and analyses how online conversations about this issue evolved over time. METHODS: A taxonomy developed and refined in collaboration with social and behaviour change teams was used to filter online conversations into nine subtopic categories. The taxonomy was applied to online content tracked in 21 countries in Eastern and Southern Africa over the period December 1, 2020-December 31, 2021. Metrics captured included volume of posts or articles and related user engagement. Qualitative analysis of content was conducted to identify key concerns, information voids and misinformation. RESULTS: Over 300,000 articles and posts about COVID-19 vaccines shared by users or outlets geolocated in the region were analysed. These results generated over 14 million engagements on social media and digital platforms. The analysis shows how conversations about access and availability of vaccines represented the largest share of engagement over the course of the period. Conversations about vaccine effectiveness and safety represented the second and third largest share of engagement, with peaks observed in August and November 2021. Online interest in childhood vaccination increased over time as vaccine eligibility criteria expanded in some countries in the region. Conversations mentioning mandates and certificates peaked in the last quarter of 2021, as governments as private sector entities expanded vaccine requirements. CONCLUSIONS: Findings from this study show the importance of monitoring conversation trends over time and adjust social listening data collection systems to include emerging topics. The study also points to the need to consider concerns, information voids and misinformation around effectiveness and safety of vaccines in the context of overall concern for vaccine availability and access in Eastern and Southern Africa. This is fundamental to inform social and behaviour change strategies that promote vaccine demand effectively, without increasing public frustration over vaccine availability challenges and downplaying concerns around vaccine equity.

Measuring behavioral and social drivers of COVID-19 vaccination in health workers in Eastern and Southern Africa.

BACKGROUND: In 2021, twenty out of twenty-one countries in the Eastern and Southern Africa (ESA) region introduced COVID-19 vaccines. With variable willingness to uptake vaccines across countries, the aim of the present study was to better understand factors that impact behavioral and social drivers of vaccination (BeSD). Using the theory-based "increasing vaccination model", the drivers Thinking & Feeling, Social Processes, Motivation, and Practical Issues were adapted to the COVID-19 context and utilized in a cross-country assessment. METHODS: Data was collected on 27.240 health workers in Kenya, Malawi, Mozambique, South Africa and South Sudan. This was done by administering a survey of seven target questions via the UNICEF Internet of Good Things (IoGT) online platform between February and August 2021. RESULTS: Findings showed a gap between perceived importance and trust in vaccines: Most health workers thought Covid-19 vaccination was very important for their health, while less than 30% trusted it very much. The pro-vaccination social and work norm was not well established since almost 66% of all respondents would take the vaccine if recommended to them, but only 49% thought most adults would, and only 48% thought their co-workers would. Access was highlighted as a crucial barrier, with less than a quarter reporting that accessing vaccination services for themselves would be very easy. Women exhibited slightly lower scores than men across the board. When testing the associations between drivers in Kenya and South Africa, it appears that when target interventions are developed for specific age groups, social norms become the main drivers of intention to get vaccinated. CONCLUSIONS: The present study revealed various key relations with demographic variables that would help immunization programmes and implementing partners to develop targeted interventions. First, there is a serious gap between perceived importance of COVID-19 vaccines and how much trust people in them. Second, problems with access are still rather serious and solving this would strongly benefit those who demand a vaccine, Third, the role of social norms is the most important predictor of willingness when considering age differences.

Midstream Players Determine Population-Level Behavior Change: Social Marketing Research to Increase Demand for Lead-Free Components in Pitcher Pumps in Madagascar.

Lead (Pb) exposure through water contamination is an important issue at the intersection of public health and water, sanitation, and hygiene (WASH). Behavior-change programs designed to address this pressing problem rarely take a behavioral-science-informed approach, nor do they consider the role of intermediate players who often influence and support behavior change. Social marketing segments the population and focuses on the consumer/user throughout program development and implementation. To illustrate the social marketing process, this cross-sectional, qualitative design study investigates the use of Pb in the construction and maintenance of household pitcher pumps for potable water in Madagascar. A sample of 18 technicians were interviewed on their current practices, motivators, barriers, and communication channels for knowledge exchange. The results reveal the importance of peers, those considered experts or "market mavens", and the need for information on the dangers of Pb as an outdated practice for any future intervention. This study advances the notion of a design shift within engineering WASH projects, whereby social/behavioral approaches are used to consider the needs, concerns, and current behaviors of the consumer. We also advocate for engaging intermediate players who often influence behavior change in the rollout of an engineering innovation.

Social Listening in Eastern and Southern Africa, a UNICEF Risk Communication and Community Engagement Strategy to Address the COVID-19 Infodemic.

The coronavirus disease 2019 (COVID-19) pandemic has been closely tied with what has been called an infodemic, a "second disease" that occurs when massive information volumes (particularly with a high prevalence of false information) hinder the public health response. In this context, social listening, the process of monitoring and analyzing conversations to inform strategic activities both online and offline, becomes an even more essential component of risk communication and engagement strategies. In the Eastern and Southern Africa region, the United Nations Children's Fund (UNICEF) and partners in the response have activated their capacity to gather insights on the information needs of the populations served to better inform and engage with local communities. We describe the social listening approach taken at the Eastern and Southern Africa regional level to respond to COVID-19 and highlight efforts by the Comoros, Kenya, Madagascar, Malawi, and Zambia UNICEF country offices to implement digital and nondigital social listening to inform risk communication and community engagement. The analysis highlights channels leveraged, types of data monitored, and provides examples of social listening data use, as well as early challenges and lessons learned.

Enhancing global health communication during a crisis: lessons from the COVID-19 pandemic.

BACKGROUND/OBJECTIVE: The understanding and practice of public health crisis communication are improved through the study of responses to past crises, but require retooling for present challenges. The 'Addressing Ebola and other outbreaks' checklist contains guiding principles built upon maxims developed from a World Health Organization consultation in response to the mad cow (bovine spongiform encephalopathy) crisis that were later adopted for Ebola. The purpose of this article is to adapt the checklist for the health communication challenges and public health practices that have emerged during the coronavirus disease 2019 (COVID-19) pandemic. The communication challenges of promoting vaccine acceptance are used to illustrate a key area that requires strengthened communication. Type of program or service: Effective communication principles for application during the COVID-19 pandemic. RESULTS: The COVID-19 pandemic has introduced unique challenges for public health practitioners and health communicators that warrant an expansion of existing health communication principles to take into consideration: the new infodemic (or mis/disinfodemic) challenge - particularly as treatments and vaccines are being developed; communication of risk and uncertainty; health-information behaviours and the instantaneous nature of social media, and the relationship between media literacy and health literacy; the effects of the pandemic on other health issues; and the need for a flexible communication strategy that adapts to the different stages of the pandemic. LESSONS LEARNT: Principles discussed in this article will help build preparedness capacity and offer communication strategies for moving from the acute phase to the 'next normal' with likely prevention (e.g. herd immunity achieved through vaccination) and societal COVID-19 resilience.

USA dental health providers' role in HPV vaccine communication and HPV-OPC protection: a systematic review.

Background. Improving human papilloma virus (HPV) vaccination coverage in the US will require healthcare providers to recommend the vaccine more effectively. To inform quality improvement efforts, we systematically reviewed studies of dental provider communication about HPV vaccination. Methods. We searched MEDLINE, CINAHL, ScienceDirect, PsycINFO and JSTOR in August 2018 to identify studies of dental provider knowledge, perceived role and communication about HPV, HPV vaccination and HPV-associated oropharyngeal cancer (HPV-OPC). Results. We identified 10 qualitative and quantitative studies. Results of the primarily descriptive studies showed that although there were some deficiencies in knowledge about HPV-related outcomes and its effect on the male population, most providers understand HPV as a sexually transmitted infection and know the HPV vaccine is available, yet many are not discussing the HPV-OPC link or recommending vaccination. Providers were less often to recommend HPV vaccination if they were uncomfortable discussing sex, perceived parents as hesitant, or believed patients to be low risk. Studies reported mixed results on providers' perceived role in expanded HPV vaccination and HPV-OPC education, but indicated support for the role of professional organizations in promoting awareness. Conclusion. Interventions are needed to help dental providers perceive their role to deliver effective recommendations within the complex communication environment surrounding HPV vaccination and HPV-OPC education.

Cost-effectiveness analysis of treatments involving radioembolization in intermediate-stage hepatocellular carcinoma.

AIM: We evaluated two treatment sequences, transarterial radioembolization followed by transarterial chemoembolization and possibly sorafenib (=TTS) versus transarterial radioembolization followed by sorafenib alone (=TS), to identify the most cost-effective pathway to treat intermediate-stage hepatocellular carcinoma from the Italian healthcare system perspective. MATERIALS & METHODS: A Markov model was developed to project costs and health outcomes for TTS and TS over a lifetime horizon. Data available at three hospitals in Italy were collected. Healthcare resource utilization was derived from standard clinical protocols. Costs were obtained from official regional tariffs. RESULTS & CONCLUSION: Taking into consideration 16 patients for TTS and 22 patients for TS pathways, the TTS sequence provided a dominant strategy in comparison to TS. Further evidence is desirable to confirm these results.

Impact of chemotherapy-induced nausea and vomiting on health-related quality of life and resource utilization: A systematic review.

BACKGROUND: Chemotherapy-induced nausea and vomiting (CINV) is a particularly distressing event for oncology patients. This review aims at analyzing the impact of CINV on Health-Related Quality of Life (QoL) and on the use of healthcare resources. METHODS: A systematic search was conducted according to the PRISMA statement on MEDLINE, EMBASE and NHS EED. RESULTS: Sixty-seven studies were included in the final selection. Despite the availability of numerous treatment options, CINV was found to have a strong impact on HRQoL of patients. Direct costs are particularly affected, but this result could be due to scarcity of studies assessing indirect costs. CONCLUSIONS: Evidence supports the notion that CINV continues to have a negative impact on HRQoL of patients, even for those receiving moderately emetic chemotherapy. Further studies need also to collect data on the cost of CINV, particularly indirect costs, to ensure that decisions on use of healthcare resources are better supported.

Prognostic Value of the Cell Cycle Progression Score in Patients with Prostate Cancer: A Systematic Review and Meta-analysis.

CONTEXT: The process of care for patients with prostate cancer is subject to different degrees of uncertainty. Patients and clinicians could, therefore, greatly benefit from improved prognostic instruments. One emerging tool is the cell cycle progression (CCP) score. OBJECTIVE: This systematic review assesses evidence on the value of the CCP instrument in prostate cancer treatment by reviewing current publications and integrating the results via a meta-analysis. EVIDENCE ACQUISITION: We performed a review of Medline and Embase in April 2014, according to Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). Unpublished studies were retrieved from the 2013-2014 proceedings of major conferences in the field. Sixteen publications were selected for inclusion. EVIDENCE SYNTHESIS: The results show that use of the CCP score is better than existing assessments at elucidating the aggressive potential of prostate cancer in an individual. The pooled hazard ratio for biochemical recurrence per 1-unit increase in the CCP score was 1.88 in a univariate model and 1.63 in a multivariate model. Four studies showed that CCP testing can impact the decisions of physicians regarding treatment, and potentially lead to a decrease in surgical interventions for low-risk patients. CONCLUSIONS: This review offers a comprehensive overview of existing evidence on CCP testing, and provides clinicians, patients, and policy makers with a strong summary measure of its prognostic validity and clinical utility. It will be important to develop economic studies to measure the impact of such technology on health care systems. PATIENT SUMMARY: In this paper, we review current evidence related to the cell cycle progression (CCP) score for patients with prostate cancer. We found good evidence suggesting that use of the CCP score improves prognosis, and can be a valuable tool for clinicians in treating patients. The economic benefits are yet to be studied.

Trans-arterial radioembolization in intermediate-advanced hepatocellular carcinoma: systematic review and meta-analyses.

Trans-arterial radioembolization (TARE) is a recognized, although not explicitly recommended, experimental therapy for unresectable hepatocellular carcinoma (HCC).A systematic literature review was performed to identify published studies on the use of TARE in intermediate and advanced stages HCC exploring the efficacy and safety of this innovative treatment.Twenty-one studies reporting data on overall survival (OS) and time to progression (TTP), were included in a meta-analysis. The pooled post-TARE OS was 63% (95% CI: 56-70%) and 27% (95% CI: 21-33%) at 1- and 3-years respectively in intermediate stage HCC, whereas OS was 37% (95% CI: 26-50%) and 13% (95% CI: 9-18%) at the same time intervals in patients with sufficient liver function (Child-Pugh A-B7) but with an advanced HCC because of the presence of portal vein thrombosis. When an intermediate and advanced case-mix was considered, OS was 58% (95% CI: 48-67%) and 17% (95% CI: 12-23%) at 1- and 3-years respectively. As for TTP, only four studies reported data: the observed progression probability was 56% (95% CI: 41-70%) and 73% (95% CI: 56-87%) at 1 and 2 years respectively. The safety analysis, focused on the risk of liver decompensation after TARE, revealed a great variability, from 0-1% to more than 36% events, influenced by the number of procedures, patient Child-Pugh stage and treatment duration.Evidence supporting the use of radioembolization in HCC is mainly based on retrospective and prospective cohort studies. Based on this evidence, until the results of the ongoing randomized trials become available, radioembolization appears to be a viable treatment option for intermediate-advanced stage HCC.

The assessment of new drugs for asthma and COPD: a Delphi study examining the perspectives of Italian payers and clinicians.

BACKGROUND: Asthma and chronic obstructive pulmonary disease (COPD) are disorders of the lungs characterized by airflow obstruction, inflammation and tissue remodeling. Management of patients with these diseases is complex and the improvement of diagnostic-therapeutic strategies represents a critical challenge for the healthcare system. In this context, investigating the criteria and information needed for an appropriate and effective evaluation of incoming treatment options is crucial to ensure that clinicians and policy-makers are provided with the best available evidence to make decisions aimed at improving patient outcomes. Therefore, the objective of this study was to investigate the degree of agreement among Health Technology Assessment (HTA) experts on issues crucial to the evaluation of new drugs for asthma and COPD and to appropriately manage the clinical pathway for patients. METHOD: This research was conducted using an e-Delphi technique organized in three subsequent rounds and involving a panel of ten experts (six regional and local payers and four clinicians). Panelists were asked to comment in written form on a set of statements, explaining qualitatively the extent to which they agreed or disagreed with the assertions. Statements were subsequently modified and resubmitted for assessment. RESULTS: Panelists expressed their opinions during each round and, after round III, a consensus document was finalized. The degree of consensus was high among experts and concerned five main topics: (a) the need to address current unmet needs of patients with asthma or COPD, (b) the importance of further studies and real-life information in the evaluation of treatments, (c) existing evidence and evidence needed to assess drugs, (d) critical issues in obtaining a positive evaluation from regional and local authorities for new treatments to be included in regional formularies and to have an important place in therapeutic categories, and (e) the major obstacles to the appropriate administration of drugs and management of patients. CONCLUSION: The final document highlights that no proof of difference among drugs exists, that evidence on final endpoints (and particularly on mortality) should be strengthened and that actions regarding risk factors, appropriate diagnosis, patient staging and adherence to therapy are particularly important for a better clinical management.