Health and equity implications of individual adaptation to air pollution in a changing climate.

Future climate change can cause more days with poor air quality. This could trigger more alerts telling people to stay inside to protect themselves, with potential consequences for health and health equity. Here, we study the change in US air quality alerts over this century due to fine particulate matter (PM2.5), who they may affect, and how they may respond. We find air quality alerts increase by over 1 mo per year in the eastern United States by 2100 and quadruple on average. They predominantly affect areas with high Black populations and leakier homes, exacerbating existing inequalities and impacting those less able to adapt. Reducing emissions can offer significant annual health benefits ($5,400 per person) by mitigating the effect of climate change on air pollution and its associated risks of early death. Relying on people to adapt, instead, would require them to stay inside, with doors and windows closed, for an extra 142 d per year, at an average cost of $11,000 per person. It appears likelier, however, that people will achieve minimal protection without policy to increase adaptation rates. Boosting adaptation can offer net benefits, even alongside deep emission cuts. New adaptation policies could, for example: reduce adaptation costs; reduce infiltration and improve indoor air quality; increase awareness of alerts and adaptation; and provide measures for those working or living outdoors. Reducing emissions, conversely, lowers everyone's need to adapt, and protects those who cannot adapt. Equitably protecting human health from air pollution under climate change requires both mitigation and adaptation.

Local Overfishing Patterns Have Regional Effects on Health of Coral, and Economic Transitions Can Promote Its Recovery.

Overfishing has the potential to severely disrupt coral reef ecosystems worldwide, while harvesting at more sustainable levels instead can boost fish yield without damaging reefs. The dispersal abilities of reef species mean that coral reefs form highly connected environments, and the viability of reef fish populations depends on spatially explicit processes such as the spillover effect and unauthorized harvesting inside marine protected areas. However, much of the literature on coral conservation and management has only examined overfishing on a local scale, without considering how different spatial patterns of fishing levels can affect reef health both locally and regionally. Here, we simulate a coupled human-environment model to determine how coral and herbivorous reef fish respond to overfishing across multiple spatial scales. We find that coral and reef fish react in opposite ways to habitat fragmentation driven by overfishing, and that a potential spillover effect from marine protected areas into overfished patches helps coral populations far less than it does reef fish. We also show that ongoing economic transitions from fishing to tourism have the potential to revive fish and coral populations over a relatively short timescale, and that large-scale reef recovery is possible even if these transitions only occur locally. Our results show the importance of considering spatial dynamics in marine conservation efforts and demonstrate the ability of economic factors to cause regime shifts in human-environment systems.

Correction: Go big or go home: A model-based assessment of general strategies to slow the spread of forest pests via infested firewood.

[This corrects the article DOI: 10.1371/journal.pone.0238979.].

When conflicts get heated, so does the planet: coupled social-climate dynamics under inequality.

Climate dynamics are inextricably linked to processes in social systems that are highly unequal. This suggests a need for coupled social-climate models that capture pervasive real-world asymmetries in the population distribution of the consequences of anthropogenic climate change and climate (in)action. Here, we use evolutionary game theory to develop a social-climate model with group structure to investigate how anthropogenic climate change and population heterogeneity coevolve. We find that greater homophily and resource inequality cause an increase in the global peak temperature anomaly by as much as 0.7°C. Also, climate change can structure human populations by driving opinion polarization. Finally, climate mitigation achieved by reducing the cost of mitigation measures paid by individuals tends to be contingent upon socio-economic conditions, whereas policies that achieve communication between different strata of society show climate mitigation benefits across a broad socio-economic regime. We conclude that advancing climate change mitigation efforts can benefit from a social-climate systems perspective.

Best response dynamics improve sustainability and equity outcomes in common-pool resources problems, compared to imitation dynamics.

Shared resource extraction among profit-seeking individuals involves a tension between individual benefit and the collective well-being represented by the persistence of the resource. Many game theoretic models explore this scenario, but these models tend to assume either best response dynamics (where individuals instantly switch to better paying strategies) or imitation dynamics (where individuals copy successful strategies from neighbours), and do not systematically compare predictions under the two assumptions. Here we propose an iterated game on a social network with payoff functions that depend on the state of the resource. Agents harvest the resource, and the strategy composition of the population evolves until an equilibrium is reached. The system is then repeatedly perturbed and allowed to re-equilibrate. We compare model predictions under best response and imitation dynamics. Compared to imitation dynamics, best response dynamics increase sustainability of the system, the persistence of cooperation while decreasing inequality and debt corresponding to the Gini index in the agents' cumulative payoffs. Additionally, for best response dynamics, the number of strategy switches before equilibrium fits a power-law distribution under a subset of the parameter space, suggesting the system is in a state of self-organized criticality. We find little variation in most mean results over different network topologies; however, there is significant variation in the distributions of the raw data, equality of payoff, clustering of like strategies and power-law fit. We suggest the primary mechanisms driving the difference in sustainability between the two strategy update rules to be the clustering of like strategies as well as the time delay imposed by an imitation processes. Given the strikingly different outcomes for best response versus imitation dynamics for common-pool resource systems, our results suggest that modellers should choose strategy update rules that best represent decision-making in their study systems.

Go big or go home: A model-based assessment of general strategies to slow the spread of forest pests via infested firewood.

Invasive pests, such as emerald ash borer or Asian longhorn beetle, have been responsible for unprecedented ecological and economic damage in eastern North America. These and other wood-boring invasive insects can spread to new areas through human transport of untreated firewood. Behaviour, such as transport of firewood, is affected not only by immediate material benefits and costs, but also by social forces. Potential approaches to reduce the spread of wood-boring pests through firewood include raising awareness of the problem and increasing the social costs of the damages incurred by transporting firewood. In order to evaluate the efficacy of these measures, we create a coupled social-ecological model of firewood transport, pest spread, and social dynamics, on a geographical network of camper travel between recreational destinations. We also evaluate interventions aimed to slow the spread of invasive pests with untreated firewood, such as inspections at checkpoints to stop the movement of transported firewood and quarantine of high-risk locations. We find that public information and awareness programs can be effective only if the rate of spread of the pest between and within forested areas is slow. Direct intervention via inspections at checkpoints can only be successful if a high proportion of the infested firewood is intercepted. Patch quarantine is only effective if sufficiently many locations can be included in the quarantine and if the quarantine begins early. Our results indicate that the current, relatively low levels of public outreach activities and lack of adequate funding are likely to render inspections, quarantine and public outreach efforts ineffective.

Global land use implications of dietary trends.

Global food security and agricultural land management represent two urgent and intimately related challenges that humans must face. We quantify the changes in the global agricultural land footprint if the world were to adhere to the dietary guidelines put forth by the United States Department of Agriculture (USDA), while accounting for the land use change incurred by import/export required to meet those guidelines. We analyze data at country, continental, and global levels. USDA guidelines are viewed as an improvement on the current land-intensive diet of the average American, but despite this our results show that global adherence to the guidelines would require 1 gigahectare of additional land-roughly the size of Canada-under current agricultural practice. The results also show a strong divide between Eastern and Western hemispheres, with many Western hemisphere countries showing net land sparing under a USDA guideline diet, while many Eastern hemisphere countries show net land use increase under a USDA guideline diet. We conclude that national dietary guidelines should be developed using not just health but also global land use and equity as criteria. Because global lands are a limited resource, national dietary guidelines also need to be coordinated internationally, in much the same way greenhouse gas emissions are increasingly coordinated.

Disease dynamics and costly punishment can foster socially imposed monogamy.

Socially imposed monogamy in humans is an evolutionary puzzle because it requires costly punishment by those who impose the norm. Moreover, most societies were--and are--polygynous; yet many larger human societies transitioned from polygyny to socially imposed monogamy beginning with the advent of agriculture and larger residential groups. We use a simulation model to explore how interactions between group size, sexually transmitted infection (STI) dynamics and social norms can explain the timing and emergence of socially imposed monogamy. Polygyny dominates when groups are too small to sustain STIs. However, in larger groups, STIs become endemic (especially in concurrent polygynist networks) and have an impact on fertility, thereby mediating multilevel selection. Punishment of polygynists improves monogamist fitness within groups by reducing their STI exposure, and between groups by enabling punishing monogamist groups to outcompete polygynists. This suggests pathways for the emergence of socially imposed monogamy, and enriches our understanding of costly punishment evolution.

National- and state-level impact and cost-effectiveness of nonavalent HPV vaccination in the United States.

Every year in the United States more than 12,000 women are diagnosed with cervical cancer, a disease principally caused by human papillomavirus (HPV). Bivalent and quadrivalent HPV vaccines protect against 66% of HPV-associated cervical cancers, and a new nonavalent vaccine protects against an additional 15% of cervical cancers. However, vaccination policy varies across states, and migration between states interdependently dilutes state-specific vaccination policies. To quantify the economic and epidemiological impacts of switching to the nonavalent vaccine both for individual states and for the nation as a whole, we developed a model of HPV transmission and cervical cancer incidence that incorporates state-specific demographic dynamics, sexual behavior, and migratory patterns. At the national level, the nonavalent vaccine was shown to be cost-effective compared with the bivalent and quadrivalent vaccines at any coverage despite the greater per-dose cost of the new vaccine. Furthermore, the nonavalent vaccine remains cost-effective with up to an additional 40% coverage of the adolescent population, representing 80% of girls and 62% of boys. We find that expansion of coverage would have the greatest health impact in states with the lowest coverage because of the decreasing marginal returns of herd immunity. Our results show that if policies promoting nonavalent vaccine implementation and expansion of coverage are coordinated across multiple states, all states benefit both in health and in economic terms.

Carrot or stick? Modelling how landowner behavioural responses can cause incentive-based forest governance to backfire.

Mitigating the negative impacts of declining worldwide forest cover remains a significant socio-ecological challenge, due to the dominant role of human decision-making. Here we use a Markov chain model of land-use dynamics to examine the impact of governance on forest cover in a region. Each land parcel can be either forested or barren (deforested), and landowners decide whether to deforest their parcel according to perceived value (utility). We focus on three governance strategies: yearly incentive for conservation, one-time penalty for deforestation and one-time incentive for reforestation. The incentive and penalty are incorporated into the expected utility of forested land, which decreases the net gain of deforestation. By analyzing the equilibrium and stability of the landscape dynamics, we observe four possible outcomes: a stationary-forested landscape, a stationary-deforested landscape, an unstable landscape fluctuating near the equilibrium, and a cyclic-forested landscape induced by synchronized deforestation. We find that the two incentive-based strategies often result in highly fluctuating forest cover over decadal time scales or longer, and in a few cases, reforestation incentives actually decrease the average forest cover. In contrast, a penalty for deforestation results in the stable persistence of forest cover (generally >30%). The idea that larger conservation incentives will always yield higher and more stable forest cover is not supported in our findings. The decision to deforest is influenced by more than a simple, "rational" cost-benefit analysis: social learning and myopic, stochastic decision-making also have important effects. We conclude that design of incentive programs may need to account for potential counter-productive long-term effects due to behavioural feedbacks.

Use of a catalytic model to estimate hepatitis A incidence in a low-endemicity country: implications for modeling immunization policies.

BACKGROUND: Evaluating the cost-effectiveness of vaccine programs with dynamic modeling requires accurate estimates of incidence over time. Because infectious diseases are often underreported, supplementary data and statistical analyses are required to estimate true incidence. This study estimates the true incidence of hepatitis A virus (HAV) infection in Canada using a catalytic model. METHODS: A catalytic model was used to reconcile HAV seroprevalence data with the corresponding true cumulative risk of infection estimated from incidence data. RESULTS: The average annual reported incidence was 6.2 cases per 100,000 from 1980 to 1989 and 7.7/100,000 from 1990 to 1999, indicating that Canada is a low-incidence country. The seroprevalence in Canadian-born individuals (n = 7 studies) was approximately 1%-8% in ages <20, 1%-11% in ages 20-29, 7%-29% in ages 30-39, and higher in older age groups. Between 1980 and 1995, the catalytic model estimated an average annual incidence of 60/100,000 (95% confidence interval, 33-524); approximately 7.73 (4.21-67.33) times the average annual reported incidence of 7.78/100,000. For a typical birth cohort of 403 434 Canadians born in 1990, the model predicted 32 750 HAV cases by age 39, with a corresponding seroprevalence of approximately 8.12% by the year 2029. IMPLICATIONS: Reliable estimates of true incidence of infectious disease are required for cost-effectiveness analysis of infectious disease programs. Catalytic models enable the synthesis of dispersed data, quantification of data limitations, and reconciliation of these limitations to estimate true incidence for economic evaluations.

Time for change? An economic evaluation of integrated cervical screening and HPV immunization programs in Canada.

Many jurisdictions have implemented universal human papillomavirus (HPV) immunization programs in preadolescent females. However, the cost-effectiveness of modified cervical screening guidelines and/or catch-up immunization in older females in Canada has not been evaluated. We conducted a cost-utility analysis of screening and immunization with the bivalent vaccine for the Canadian setting from the Ministry of Health perspective. We used a dynamic model to capture herd immunity and included cross-protection against strains not included in the vaccine. We found that adding catch-up immunization to the current program would be cost-effective, and that combining catch-up immunization with delaying the age at which screening is first initiated could result in cost savings and net health gains.

The potential impact of immunization campaign budget re-allocation on global eradication of paediatric infectious diseases.

BACKGROUND: The potential benefits of coordinating infectious disease eradication programs that use campaigns such as supplementary immunization activities (SIAs) should not be over-looked. One example of a coordinated approach is an adaptive "sequential strategy": first, all annual SIA budget is dedicated to the eradication of a single infectious disease; once that disease is eradicated, the annual SIA budget is re-focussed on eradicating a second disease, etc. Herd immunity suggests that a sequential strategy may eradicate several infectious diseases faster than a non-adaptive "simultaneous strategy" of dividing annual budget equally among eradication programs for those diseases. However, mathematical modeling is required to understand the potential extent of this effect. METHODS: Our objective was to illustrate how budget allocation strategies can interact with the nonlinear nature of disease transmission to determine time to eradication of several infectious diseases under different budget allocation strategies. Using a mathematical transmission model, we analyzed three hypothetical vaccine-preventable infectious diseases in three different countries. A central decision-maker can distribute funding among SIA programs for these three diseases according to either a sequential strategy or a simultaneous strategy. We explored the time to eradication under these two strategies under a range of scenarios. RESULTS: For a certain range of annual budgets, all three diseases can be eradicated relatively quickly under the sequential strategy, whereas eradication never occurs under the simultaneous strategy. However, moderate changes to total SIA budget, SIA frequency, order of eradication, or funding disruptions can create disproportionately large differences in the time and budget required for eradication under the sequential strategy. We find that the predicted time to eradication can be very sensitive to small differences in the rate of case importation between the countries. We also find that the time to eradication of all three diseases is not necessarily lowest when the least transmissible disease is targeted first. CONCLUSIONS: Relatively modest differences in budget allocation strategies in the near-term can result in surprisingly large long-term differences in time required to eradicate, as a result of the amplifying effects of herd immunity and the nonlinearities of disease transmission. More sophisticated versions of such models may be useful to large international donors or other organizations as a planning or portfolio optimization tool, where choices must be made regarding how much funding to dedicate to different infectious disease eradication efforts.

Assessing the cost-effectiveness of measles elimination in Uganda: local impact of a global eradication program.

BACKGROUND: Measles control has succeeded worldwide, and many countries have substantially reduced incidence and mortality. This has led to consideration of the feasibility of measles elimination in Uganda within the context of global eradication. Before an elimination program is initiated, it is important to consider its potential economic impact, including its cost-effectiveness. METHODS: Incremental cost-effectiveness ratios (ICERs) were estimated for measles mortality reduction and measles elimination in Uganda. A dynamic age-structured compartmental model of measles transmission was used to simulate scenarios and estimate health outcomes and costs. The main outcome measures were costs, measles cases, measles deaths, disability-adjusted life-years (DALYs), and ICERs measured as cost per DALY averted through either the year 2030 or 2050. RESULTS: Measles elimination by 2020 averted 130,232 measles cases, 3520 measles deaths, and 106,330 DALYs through the year 2030, compared with the next best scenario (95% mortality reduction by 2015), and it was the most cost-effective strategy, with ICERs of $556 per DALY averted (2030 time horizon) and $284 per DALY averted (2050 time horizon). CONCLUSIONS: Measles elimination in Uganda, as part of a global eradication program, is projected to be highly cost-effective and should be considered among the available policy options for dealing with the disease.

Using cost-effectiveness analysis to support research and development portfolio prioritization for product innovations in measles vaccination.

BACKGROUND: Several potential measles vaccine innovations are in development to address the shortcomings of the current vaccine. Funders need to prioritize their scarce research and development resources. This article demonstrates the usefulness of cost-effectiveness analysis to support these decisions. METHODS: This study had 4 major components: (1) identifying potential innovations, (2) developing transmission models to assess mortality and morbidity impacts, (3) estimating the unit cost impacts, and (4) assessing aggregate cost-effectiveness in United Nations Children's Fund countries through 2049. RESULTS: Four promising technologies were evaluated: aerosol delivery, needle-free injection, inhalable dry powder, and early administration DNA vaccine. They are projected to have a small absolute impact in terms of reducing the number of measles cases in most scenarios because of already improving vaccine coverage. Three are projected to reduce unit cost per dose by $0.024 to $0.170 and would improve overall cost-effectiveness. Each will require additional investments to reach the market. Over the next 40 years, the aggregate cost savings could be substantial, ranging from $98.4 million to $689.4 million. CONCLUSIONS: Cost-effectiveness analysis can help to inform research and development portfolio prioritization decisions. Three new measles vaccination technologies under development hold promise to be cost-saving from a global perspective over the long-term, even after considering additional investment costs.

"Wait and see" vaccinating behaviour during a pandemic: a game theoretic analysis.

During the 2009 H1N1 pandemic, many individuals did not seek vaccination immediately but rather decided to "wait and see" until further information was available on vaccination costs. This behaviour implies two sources of strategic interaction: as more individuals become vaccinated, both the perceived vaccination cost and the probability that susceptible individuals become infected decline. Here we analyze the outcome of these two strategic interactions by combining game theory with a disease transmission model during an outbreak of a novel influenza strain. The model exhibits a "wait and see" Nash equilibrium strategy, with vaccine delayers relying on herd immunity and vaccine safety information generated by early vaccinators. This strategic behaviour causes the timing of the epidemic peak to be strongly conserved across a broad range of plausible transmission rates, in contrast to models without such adaptive behaviour. The model exhibits not only feedback mechanisms but also a feed-forward mechanism: a high initial perceived vaccination cost perpetuates high perceived vaccine costs (and lower vaccine coverage) throughout the remainder of the outbreak. This suggests that any effect of risk communication at the start of a pandemic outbreak will be amplified compared to the same amount of risk communication effort distributed throughout the outbreak.

Is a mass immunization program for pandemic (H1N1) 2009 good value for money? Evidence from the Canadian Experience.

In response to the pandemic H1N1 influenza 2009 outbreak, many jurisdictions undertook mass immunization programs that were among the largest in recent history. The objective of this study was to determine the cost-effectiveness of the mass H1N1 immunization program in Ontario, Canada's most populous province (population 13,000,000). This analysis suggests that a mass immunization program as carried out in Ontario and many other high-income health care systems in response to H1N1 2009 was effective in preventing influenza cases and health care resource use and was also highly cost-effective despite the substantial program cost.

Economic appraisal of Ontario's Universal Influenza Immunization Program: a cost-utility analysis.

BACKGROUND: In July 2000, the province of Ontario, Canada, initiated a universal influenza immunization program (UIIP) to provide free seasonal influenza vaccines for the entire population. This is the first large-scale program of its kind worldwide. The objective of this study was to conduct an economic appraisal of Ontario's UIIP compared to a targeted influenza immunization program (TIIP). METHODS AND FINDINGS: A cost-utility analysis using Ontario health administrative data was performed. The study was informed by a companion ecological study comparing physician visits, emergency department visits, hospitalizations, and deaths between 1997 and 2004 in Ontario and nine other Canadian provinces offering targeted immunization programs. The relative change estimates from pre-2000 to post-2000 as observed in other provinces were applied to pre-UIIP Ontario event rates to calculate the expected number of events had Ontario continued to offer targeted immunization. Main outcome measures were quality-adjusted life years (QALYs), costs in 2006 Canadian dollars, and incremental cost-utility ratios (incremental cost per QALY gained). Program and other costs were drawn from Ontario sources. Utility weights were obtained from the literature. The incremental cost of the program per QALY gained was calculated from the health care payer perspective. Ontario's UIIP costs approximately twice as much as a targeted program but reduces influenza cases by 61% and mortality by 28%, saving an estimated 1,134 QALYs per season overall. Reducing influenza cases decreases health care services cost by 52%. Most cost savings can be attributed to hospitalizations avoided. The incremental cost-effectiveness ratio is Can$10,797/QALY gained. Results are most sensitive to immunization cost and number of deaths averted. CONCLUSIONS: Universal immunization against seasonal influenza was estimated to be an economically attractive intervention.

A cost-utility analysis of cervical cancer vaccination in preadolescent Canadian females.

BACKGROUND: Despite the fact that approximately 70% of Canadian women undergo cervical cancer screening at least once every 3 years, approximately 1,300 women were diagnosed with cervical cancer and approximately 380 died from it in 2008. This study estimates the effectiveness and cost-effectiveness of vaccinating 12-year old Canadian females with an AS04-adjuvanted cervical cancer vaccine. The indirect effect of vaccination, via herd immunity, is also estimated. METHODS: A 12-health-state 1-year-cycle Markov model was developed to estimate lifetime HPV related events for a cohort of 12-year old females. Annual transition probabilities between health-states were derived from published literature and Canadian population statistics. The model was calibrated using Canadian cancer statistics. From a healthcare perspective, the cost-effectiveness of introducing a vaccine with efficacy against HPV-16/18 and evidence of cross-protection against other oncogenic HPV types was evaluated in a population undergoing current screening practices. The base-case analysis included 70% screening coverage, 75% vaccination coverage, $135/dose for vaccine, and 3% discount rate on future costs and health effects. Conservative herd immunity effects were taken into account by estimated HPV incidence using a mathematical model parameterized by reported age-stratified sexual mixing data. Sensitivity analyses were performed to address parameter uncertainties. RESULTS: Vaccinating 12-year old females (n = 100,000) was estimated to prevent between 390-633 undiscounted cervical cancer cases (reduction of 47%-77%) and 168-275 undiscounted deaths (48%-78%) over their lifetime, depending on whether or not herd immunity and cross-protection against other oncogenic HPV types were included. Vaccination was estimated to cost $18,672-$31,687 per QALY-gained, the lower range representing inclusion of cross-protective efficacy and herd immunity. The cost per QALY-gained was most sensitive to duration of vaccine protection, discount rate, and the correlation between probability of screening and probability of vaccination. CONCLUSION: In the context of current screening patterns, vaccination of 12-year old Canadian females with an ASO4-ajuvanted cervical cancer vaccine is estimated to significantly reduce cervical cancer and mortality, and is a cost-effective option. However, the economic attractiveness of vaccination is impacted by the vaccine's duration of protection and the discount rate used in the analysis.

Incorporating herd immunity effects into cohort models of vaccine cost-effectiveness.

BACKGROUND: Cohort models are often used in cost-effectiveness analysis (CEA) of vaccination. However, because they cannot capture herd immunity effects, cohort models underestimate the reduction in incidence caused by vaccination. Dynamic models capture herd immunity effects but are often not adopted in vaccine CEA. OBJECTIVE: The objective was to develop a pseudo-dynamic approximation that can be incorporated into an existing cohort model to capture herd immunity effects. METHODS: The authors approximated changing force of infection due to universal vaccination for a pediatric infectious disease. The projected lifetime cases in a cohort were compared under 1) a cohort model, 2) a cohort model with pseudo-dynamic approximation, and 3) an age-structured susceptible-exposed-infectious-recovered compartmental (dynamic) model. The authors extended the methodology to sexually transmitted infections. RESULTS: For average to high values of vaccine coverage (P > 60%) and small to average values of the basic reproduction number (R(0) < 10), which describes school-based vaccination programs for many common infections, the pseudo-dynamic approximation significantly improved projected lifetime cases and was close to projections of the full dynamic model. For large values of R(0) (R(0) > 15), projected lifetime cases were similar under the dynamic model and the cohort model, both with and without pseudo-dynamic approximation. The approximation captures changes in the mean age at infection in the 1st vaccinated cohort. CONCLUSIONS: This methodology allows for preliminary assessment of herd immunity effects on CEA of universal vaccination for pediatric infectious diseases. The method requires simple adjustments to an existing cohort model and less data than a full dynamic model.