The economic burden of RSV-associated illness in children aged < 5 years, South Africa 2011-2016.

BACKGROUND: Data on the economic burden of RSV-associated illness will inform decisions on the programmatic implementation of maternal vaccines and monoclonal antibodies. We estimated the cost of RSV-associated illness in fine age bands to allow more accurate cost-effectiveness models to account for a limited duration of protection conferred by short- or long-acting interventions. METHODS: We conducted a costing study at sentinel sites across South Africa to estimate out-of-pocket and indirect costs for RSV-associated mild and severe illness. We collected facility-specific costs for staffing, equipment, services, diagnostic tests, and treatment. Using case-based data we calculated a patient day equivalent (PDE) for RSV-associated hospitalizations or clinic visits; the PDE was multiplied by the number of days of care to provide a case cost to the healthcare system. We estimated the costs in 3-month age intervals in children aged < 1 year and as a single group for children aged 1-4 years. We then applied our data to a modified version of the World Health Organization tool for estimating the mean annual national cost burden, including medically and non-medically attended RSV-associated illness. RESULTS: The estimated mean annual cost of RSV-associated illness in children aged < 5 years was US dollars ($)137,204,393, of which 76% ($111,742,713) were healthcare system incurred, 6% ($8,881,612) were out-of-pocket expenses and 13% ($28,225,.801) were indirect costs. Thirty-three percent ($45,652,677/$137,204,393) of the total cost in children aged < 5 years was in the < 3-month age group, of which 52% ($71,654,002/$137,204,393) were healthcare system incurred. The costs of non-medically attended cases increased with age from $3,307,218 in the < 3-month age group to $8,603,377 in the 9-11-month age group. CONCLUSIONS: Among children < 5 years of age with RSV in South Africa, the highest cost burden was in the youngest infants; therefore, interventions against RSV targeting this age group are important to reduce the health and cost burden of RSV-associated illness.

Consolidation regimens in primary central nervous system lymphoma: a single-center retrospective cohort evaluating survival outcomes and cost-benefit analysis.

ABSTRACT: PURPOSE: Optimal treatment for primary central nervous system lymphoma (PCNSL) comprises polychemotherapy induction with high-dose methotrexate followed by consolidation therapy, but there is no standard treatment regimen because of a lack of comparative trials examining efficacy or relative value. We performed a retrospective outcome and relative cost analysis on consolidation regimens to gain perspective on how cost and benefit can be weighed in medical decisions for patients with PCNSL. METHODS: Patients with newly diagnosed PCNSL who completed consolidation at our institution from July 1, 2012, to March 1, 2019, were included. Patients completed etoposide/cytarabine (EA), high-dose cytarabine (HIDAC), or high-dose chemotherapy with autologous stem-cell rescue (HDC-ASCR) as consolidation regimen. Data were collected from the electronic medical record and our institution's Value Driven Outcomes tool. Survival was analyzed as date of diagnosis to last known date of survival. RESULTS: Of the 22 patients included in the study, 12 completed the EA regimen, 4 completed HDC-ASCR, and 6 completed HIDAC. Facility and pharmacy costs contributed most to the cost of each treatment. HDC-ASCR treatment was 50× the cost of the cheapest treatment, HIDAC. Outcomes were numerically superior with HDC-ASCR and HIDAC compared with EA (2-year progression-free survival 100% vs. 100% vs. 63.6%, respectively, p = 0.1915). CONCLUSION: This small retrospective cost-benefit analysis provides evidence that HDC-ASCR may be a superior treatment for PCNSL but at a higher cost than other consolidation regimens. HIDAC may increase value for patients, including elderly patients, who are not appropriate candidates for HDC-ASCR when compared with EA.

Caregiver burden by treatment and clinical characteristics of patients with glioblastoma.

BACKGROUND: Glioblastoma is an incurable disease with a poor prognosis. For caregivers of people with glioblastoma, the burden of care can be high. Patients often present with different clinical characteristics, which may impact caregiver burden in different ways. This study aimed to evaluate associations between patient clinical characteristics and caregiver burden/quality of life (QoL). METHODS: Caregiver-patient dyads were enrolled at 7 academic cancer centers in the United States. Eligible caregiver participants were self-reported as the primary caregiver of an adult living with glioblastoma and completed a caregiver burden survey. Eligible patients were age ≥ 18 years at glioblastoma diagnosis and alive when their respective caregiver entered the study, with the presence of cognitive dysfunction confirmed by the caregiver. Data were analyzed with descriptive statistics and multivariable analyses. RESULTS: The final cohort included 167 dyads. Poor patient performance status resulted in patient difficulty with mental tasks, more caregiving tasks, and increased caregiving time. Language problems were reported in patients with left-sided lesions. Patient confusion was negatively associated with all caregiver domains: emotional health, social health, general health, ability to work, confidence in finances, and overall QoL. Better caregiver QoL was observed in patients with frontal lobe lesions versus non-frontal lobe lesions. CONCLUSION: This study reinforced that patient performance status is a critical clinical factor that significantly affects caregiver burden, caregiving tasks, and caregiver time. Additionally, patient confusion affects multiple facets of caregiver burden/QoL. These results could be used to support guided intervention for caregiver support, customized to the patient experience.

Vaccine preventable diseases surveillance in Nepal: How much does it cost?

Assessing the cost of vaccine preventable diseases (VPD) surveillance is becoming more important in the context of the Global Polio Eradication Initiative (GPEI) funding transition, since GPEI support to polio surveillance helped the incremental building of VPD surveillance systems in many countries, including low income countries such as Nepal. However, there is limited knowledge on the cost of conducting VPD surveillance, especially the national cost for surveillance of multiple vaccine-preventable diseases. The current study sought to calculate the economic and financial costs of Nepal's comprehensive VPD surveillance systems from July 2016 to July 2017. At thecentral level, all surveillance units were included in the sample. At sub-national level, a purposive sampling strategy was used to select a representative sample from locations involved in conducting surveillance. The sub-national sample costs were extrapolated to the nationwide VPD surveillance system. Nepal's total annual economic cost of VPD surveillance was USD 4.81 million or USD 0.18 per capita, while the total financial cost was USD 4.38 million or USD 0.16 per capita. Government expenditures accounted for 56% of the total economic cost, and World Health Organization accounting for 44%. The biggest cost driver was personnel accounting for 51% of the total economic cost. WHO supported trained surveillance personnel through donor funding, mainly from Global Polio Eradication Initiative. As a polio transition priority country, Nepal will need to make strategic choices to fully self-finance or seek full donor support or a mixed-financing model as polio program funding diminishes.

Influenza economic burden among potential target risk groups for immunization in South Africa, 2013-2015.

BACKGROUND: Data on influenza economic burden in risk groups for severe influenza are important to guide targeted influenza immunization, especially in resource-limited settings. However, this information is limited in low- and middle-income countries. METHODS: We estimated the cost (from a health system and societal perspective) and years of life lost (YLL) for influenza-associated illness in South Africa during 2013-2015 among (i) children aged 6-59 months, (ii) individuals aged 5-64 years with HIV, pulmonary tuberculosis (PTB) and selected underlying medical conditions (UMC), separately, (iii) pregnant women and (iv) individuals aged ≥65 years, using publicly available data and data collected through laboratory-confirmed influenza surveillance and costing studies. All costs were expressed in 2015 prices using the South Africa all-items Consumer Price Index. RESULTS: During 2013-2015, the mean annual cost of influenza-associated illness among the selected risk groups accounted for 52.1% ($140.9/$270.5 million) of the total influenza-associated illness cost (for the entire population of South Africa), 45.2% ($52.2/$115.5 million) of non-medically attended illness costs, 43.3% ($46.7/$107.9 million) of medically-attended mild illness costs and 89.3% ($42.0/$47.1 million) of medically-attended severe illness costs. The YLL among the selected risk groups accounted for 86.0% (262,069 /304,867 years) of the total YLL due to influenza-associated death. CONCLUSION: In South Africa, individuals in risk groups for severe influenza accounted for approximately half of the total influenza-associated illness cost but most of the cost of influenza-associated medically attended severe illness and YLL. This study provides the foundation for future studies on the cost-effectiveness of influenza immunization among risk groups.

Influenza disease burden among potential target risk groups for immunization in South Africa, 2013-2015.

BACKGROUND: Data on influenza burden in risk groups for severe influenza are important to guide targeted influenza immunization, especially in resource limited settings. However, this information is limited overall and in particular in low- and middle-income countries. We sought to assess the mean annual national burden of medically and non-medically attended influenza-associated mild, severe-non-fatal and fatal illness among potential target groups for influenza immunization in South Africa during 2013-2015. METHODS: We used published mean national annual estimates of mild, severe-non-fatal, and fatal influenza-associated illness in South Africa during 2013-2015 and estimated the number of such illnesses occurring among the following risk groups: (i) children aged 6-59 months; (ii) individuals aged 5-64 years with HIV, and/or pulmonary tuberculosis (PTB), and/or selected underlying medical conditions (UMC); (iii) pregnant women; and (iv) individuals aged ≥65 years. We also estimated the number of individuals among the same risk groups in the population. RESULTS: During 2013-2015, individuals in the selected risk groups accounted for 45.3% (24,569,328/54,086,144) of the population and 43.5% (4,614,763/10,598,138), 86.8% (111,245/128,173) and 94.5% (10,903/11,536) of the mean annual estimated number of influenza-associated mild, severe-non-fatal and fatal illness episodes, respectively. The rates of influenza-associated illness were highest in children aged 6-59 months (23,983 per 100,000 population) for mild illness, in pregnant women (930 per 100,000 population) for severe-non-fatal illness and in individuals aged ≥65 years (138 per 100,000 population) for fatal illness. CONCLUSION: Influenza immunization of the selected risk groups has the potential to prevent a substantial number of influenza-associated severe illness. Nonetheless, because of the high number of individuals at risk, South Africa, due to financial resources constrains, may need to further prioritize interventions among risk populations. Cost-burden and cost-effectiveness estimates may assist with further prioritization.

A cost-effectiveness analysis of antenatal influenza vaccination among HIV-infected and HIV-uninfected pregnant women in South Africa.

BACKGROUND: Pregnant women and infants are at increased risk of severe disease from influenza. Antenatal influenza vaccination is safe and can reduce the risk of illness for women and their infants. We evaluated for South Africa the health effects of antenatal influenza vaccination among pregnant women and their infants aged <6 months old and assessed its cost-effectiveness. METHODS: We constructed a decision tree model to simulate the population of pregnant women and infants aged <6 months in South Africa using TreeAge Pro Suite 2015. The model evaluated the change in societal costs and outcomes associated with a vaccination campaign that prioritized HIV-infected over HIV-uninfected pregnant women compared with no vaccination. We also examined the impacts of a campaign without prioritization. Upper and lower 90% uncertainty intervals (90% UI) were generated using probabilistic sensitivity analysis on 10000 Monte Carlo simulations. The cost-effectiveness threshold was set to the 2015 per capita gross domestic product of South Africa, US$5724. RESULTS: Antenatal vaccination with prioritization averted 9070 (90% UI: 7407-11217) total cases of influenza among pregnant women and infants, including 411 (90% UI: 305-546) hospitalizations and 30 (90% UI: 22-40) deaths. This corresponds to an averted fraction of 13.5% (90% UI: 9.0-20.5%). Vaccinating without prioritization averted 7801 (90% UI: 6465-9527) cases of influenza, including 335 (90% UI: 254-440) hospitalizations and 24 (90% UI: 18-31) deaths. This corresponds to an averted fraction of 11.6% (90% UI: 7.8-17.4%). Vaccinating the cohort of pregnant women with prioritization had societal cost of $4689 (90% UI: $3128-$7294) per Quality Adjusted Life Year (QALY) gained while vaccinating without prioritization had a cost of $5924 (90% UI: $3992-$9056) per QALY. CONCLUSIONS: Antenatal influenza vaccination campaigns in South Africa would reduce the impact of influenza and could be cost-effective.

Health and economic burden of influenza-associated illness in South Africa, 2013-2015.

BACKGROUND: Economic burden estimates are essential to guide policy-making for influenza vaccination, especially in resource-limited settings. METHODS: We estimated the cost, absenteeism, and years of life lost (YLL) of medically and non-medically attended influenza-associated mild and severe respiratory, circulatory and non-respiratory/non-circulatory illness in South Africa during 2013-2015 using a modified version of the World Health Organization (WHO) worksheet based tool for estimating the economic burden of seasonal influenza. Additionally, we restricted the analysis to influenza-associated severe acute respiratory illness (SARI) and influenza-like illness (ILI; subsets of all-respiratory illnesses) as suggested in the WHO manual. RESULTS: The estimated mean annual cost of influenza-associated illness was $270.5 million, of which $111.3 million (41%) were government-incurred costs, 40.7 million (15%) were out-of-pocket expenses, and $118.4 million (44%) were indirect costs. The cost of influenza-associated medically attended mild illness ($107.9 million) was 2.3 times higher than that of severe illness ($47.1 million). Influenza-associated respiratory illness costs ($251.4 million) accounted for 93% of the total cost. Estimated absenteeism and YLL were 13.2 million days and 304 867 years, respectively. Among patients with influenza-associated WHO-defined ILI or SARI, the costs ($95.3 million), absenteeism (4.5 million days), and YLL (65 697) were 35%, 34%, and 21% of the total economic and health burden of influenza. CONCLUSION: The economic burden of influenza-associated illness was substantial from both a government and a societal perspective. Models that limit estimates to those obtained from patients with WHO-defined ILI or SARI substantially underestimated the total economic and health burden of influenza-associated illness.

Quantifying How Different Clinical Presentations, Levels of Severity, and Healthcare Attendance Shape the Burden of Influenza-associated Illness: A Modeling Study From South Africa.

BACKGROUND: Burden estimates of medically and nonmedically attended influenza-associated illness across syndromes and levels of severity are lacking. METHODS: We estimated the national burden of medically and nonmedically attended influenza-associated illness among individuals with different clinical presentations (all-respiratory, all-circulatory, and nonrespiratory/noncirculatory) and levels of severity (mild, fatal, and severe, nonfatal) using a combination of case-based (from laboratory-confirmed influenza surveillance) and ecological studies, as well as data from healthcare utilization surveys in South Africa during 2013-2015. In addition, we compared estimates of medically attended influenza-associated respiratory illness, obtained from case-based and ecological studies. Rates were reported per 100 000 individuals in the population. RESULTS: The estimated mean annual number of influenza-associated illness episodes was 10 737 847 (19.8% of 54 096 705 inhabitants). Of these episodes, 10 598 138 (98.7%) were mild, 128 173 (1.2%) were severe, nonfatal, and 11 536 (0.1%) were fatal. There were 2 718 140 (25.6%) mild, 56 226 (43.9%) severe, nonfatal, and 4945 (42.8%) medically attended should be after fatal episodes. Influenza-associated respiratory illness accounted for 99.2% (10 576 146) of any mild, 65.5% (83 941) of any severe, nonfatal, and 33.7% (3893) of any fatal illnesses. Ecological and case-based estimates of medically attended, influenza-associated, respiratory mild (rates: ecological, 1778.8, vs case-based, 1703.3; difference, 4.4%), severe, nonfatal (rates: ecological, 88.6, vs case-based, 75.3; difference, 15.0%), and fatal (rates: ecological, 3.8, vs case-based, 3.5; difference, 8.4%) illnesses were similar. CONCLUSIONS: There was a substantial burden of influenza-associated symptomatic illness, including severe, nonfatal and fatal illnesses, and a large proportion was nonmedically attended. Estimates, including only influenza-associated respiratory illness, substantially underestimated influenza-associated, severe, nonfatal and fatal illnesses. Ecological and case-based estimates were found to be similar for the compared categories.

Expenditures on vaccine-preventable disease surveillance: Analysis and evaluation of comprehensive multi-year plans (cMYPs) for immunization.

Despite the importance of vaccine-preventable disease (VPD) surveillance, little is known about the costs of monitoring disease. We used Comprehensive Multi-Year Plans for Immunization (cMYPs) - developed by countries following guidelines from the World Health Organization and United Nations Children's Fund - to estimate expenditures on VPD surveillance at the country level in 2015 US Dollars (USD) in 63 low- and middle-income countries. To evaluate the reliability of cMYP estimates, we also compared cMYP data with findings from previous research studies and assessed whether countries explicitly budgeted for major categories of surveillance activities in their plans for immunization. According to our analysis of cMYPs, countries spent an annual median of $406,108 on VPD surveillance ($0.04 per capita and $1.47 per infant), with reported expenditures ranging from $1,098 (Kiribati) to $21,644,770 (Nigeria). However, the majority of countries failed to explicitly mention several key categories of surveillance activities in their plans, especially laboratory-related surveillance activities. Our results show a large amount of variation in surveillance expenditures (total, per capita, and per infant) between countries and provide insights to improve costing guidelines and practices.

Using surveillance and economic data to make informed decisions about rotavirus vaccine introduction.

While rotavirus vaccines are available, safe, and effective, many countries are not yet widely using these vaccines. Surveillance for rotavirus disease and potential vaccine adverse events is critical for country decision making about rotavirus vaccine. This special issue shares rotavirus and intussusception disease surveillance data and rotavirus vaccine cost-effectiveness analyses from countries that have yet to introduce rotavirus vaccines into their routine infant immunization programs. The studies highlight the substantial burden of rotavirus disease and the cost-effectiveness of rotavirus vaccine in a broad set of countries without rotavirus vaccine in their routine immunization programs.

Impact of rotavirus vaccines in Sub-Saharan African countries.

By the end of 2017, 32 (68%) of 47 countries in the World Health Organization's African Region had introduced rotavirus vaccine into their national immunization programs, including 27 countries that received financial support from the Gavi, the Vaccine Alliance. Several early introducing African countries previously evaluated the impact, vaccine effectiveness, and/or cost effectiveness of their routine rotavirus vaccination programs and found that rotavirus vaccine was effective and resulted in substantial declines in hospitalizations due to rotavirus. This Special Issue of Vaccine provides additional rotavirus vaccine effectiveness and impact data from a broader range of African countries, describes the longer term impact and potential indirect benefits of rotavirus vaccination programs, describes trends in circulating genotypes in the pre- and post-vaccine introduction eras, and evaluates the cost-effectiveness of a rotavirus vaccination program in a post-introduction setting. As countries begin transitioning from Gavi support, the findings of these studies provide evidence of the impact and effectiveness of rotavirus vaccination programs under conditions of routine use.

Rotavirus gastroenteritis surveillance in Azerbaijan, 2011-2016.

INTRODUCTION: Rotavirus is a leading cause of acute gastroenteritis and mortality among children worldwide but data describing rotavirus disease in Azerbaijan are lacking. This analysis describes the rotavirus disease burden in Baku, the largest city in Azerbaijan. METHODS: We conducted active, prospective, sentinel hospital surveillance with laboratory confirmation for rotavirus among children under 5 years of age hospitalized at a large pediatric hospital in Baku during 2011-2016. Children with bloody diarrhea, or prior use of antibiotics or intravenous fluids were excluded. The guardians of enrolled children completed a questionnaire documenting clinical and demographic information. A stool specimen was collected from each enrolled child. We report the number and proportion of rotavirus positive hospitalizations during the surveillance period and a clinical description of rotavirus-positive and rotavirus-negative children. RESULTS: From July 2011 through June 2016, 3139 children <5 years of age were enrolled into the surveillance system. Of these, 523 (17%) were positive for rotavirus, varying from 13% to 21% by surveillance year, with a median of 16% over the surveillance period. Increase in rotavirus detections occurred during December-May. Most rotavirus infections (303/523; 58%) occurred in children aged 6-23 months. CONCLUSION: Rotavirus is responsible for approximately 16% of annual hospital admissions for acute gastroenteritis in children <5 years of age in Baku. This is lower than regional estimates. Exclusion of children with a history of antibiotic use or intravenous fluids may be accounting for this lower prevalence, and expansion of surveillance to include these groups could provide a more comprehensive picture of acute rotavirus gastroenteritis in Baku.

The effects of the attributable fraction and the duration of symptoms on burden estimates of influenza-associated respiratory illnesses in a high HIV prevalence setting, South Africa, 2013-2015.

BACKGROUND: The attributable fraction of influenza virus detection to illness (INF-AF) and the duration of symptoms as a surveillance inclusion criterion could potentially have substantial effects on influenza disease burden estimates. METHODS: We estimated rates of influenza-associated influenza-like illness (ILI) and severe acute (SARI-10) or chronic (SCRI-10) respiratory illness (using a symptom duration cutoff of ≤10 days) among HIV-infected and HIV-uninfected patients attending 3 hospitals and 2 affiliated clinics in South Africa during 2013-2015. We calculated the unadjusted and INF-AF-adjusted rates and relative risk (RR) due to HIV infection. Rates were expressed per 100 000 population. RESULTS: The estimated mean annual unadjusted rates of influenza-associated illness were 1467.7, 50.3, and 27.4 among patients with ILI, SARI-10, and SCRI-10, respectively. After adjusting for the INF-AF, the percent reduction in the estimated rates was 8.9% (rate: 1336.9), 11.0% (rate: 44.8), and 16.3% (rate: 22.9) among patients with ILI, SARI-10, and SCRI-10, respectively. HIV-infected compared to HIV-uninfected individuals experienced a 2.3 (95% CI: 2.2-2.4)-, 9.7 (95% CI: 8.0-11.8)-, and 10.0 (95% CI: 7.9-12.7)-fold increased risk of influenza-associated illness among patients with ILI, SARI-10, and SCRI-10, respectively. Overall 34% of the estimated influenza-associated hospitalizations had symptom duration of >10 days; 8% and 44% among individuals aged <5 and ≥5 years, respectively. CONCLUSION: The marginal differences between unadjusted and INF-AF-adjusted rates are unlikely to affect policies on prioritization of interventions. HIV-infected individuals experienced an increased risk of influenza-associated illness and may benefit more from annual influenza immunization. The use of a symptom duration cutoff of ≤10 days may underestimate influenza-associated disease burden, especially in older individuals.

Observations on the epidemiology of rotavirus infection among hospitalized children younger than 5 years in 2 Ukrainian hospitals, 2007-2015.

BACKGROUND: Acute gastroenteritis remains a burden among children under 5 years of age. Ukraine joined the World Health Organization's Global Rotavirus Surveillance Network in 2006, with a goal of providing accurate rotavirus burden data to aid policy makers in planning for rotavirus vaccine introduction. This analysis describes rotavirus epidemiology among Ukrainian children enrolled in Kyiv and Odesa, two large Ukrainian cities. METHODS: Children 0-59 months of age hospitalized for acute gastroenteritis at 2 sentinel sites in Kyiv and Odesa were enrolled into the active, prospective surveillance program. In Odesa, the surveillance period was during 2007-2015 and in Kyiv, it was during 2011-2015. Acute gastroenteritis was defined as 3 or more episodes of diarrhea per day during a 24 h period, with symptom duration before hospitalization not exceeding 7 days. Guardians of enrolled children completed a questionnaire including demographic, clinical and treatment information. Each child provided a stool specimen within 2 days of hospitalization. Stools were tested for rotavirus using ProSpecT™ Rotavirus Kit (Oxoid Ltd., Great Britain), and positive specimens were genotyped. Descriptive data are reported, as well as comparison of demographic, clinical and treatment data among rotavirus positive and negative children. RESULTS: During July 2007-June 2015, 12,350 children were enrolled in the surveillance programs and had stool specimens collected and tested for rotavirus. Overall, rotavirus infection was diagnosed in 5412/12350 (44%) of children, 929/1734 (54%) of those in Kyiv and 4483/10616 (42%) in Odesa. Rotavirus infections peaked during the winter months. Children with rotavirus acute gastroenteritis displayed more severe clinical symptoms than those without rotavirus. Predominant genotypes identified included G1P[8], G2P[4], G3 P[8], G4 P[8] and G9 P[8]. CONCLUSION: Active surveillance of acute gastroenteritis in hospitalized children younger 5 years in two large Ukrainian cities reveals a significant burden of rotavirus infection. These data provide scientific justification for incorporating rotavirus vaccines into the Ukrainian national immunization schedule.

Development of the Electronic Social Network Assessment Program Using the Center for eHealth and Wellbeing Research Roadmap.

BACKGROUND: The number of Web-based psychological and behavioral interventions is growing. Beyond their theoretical underpinnings, a key factor to the success of these interventions is how they are designed and developed to ensure usability over a new method of delivery. Our team has adapted ecomapping, a tool for visualizing family caregiver social network resources, for the Web. Here, we describe how we designed and developed the electronic Social Network Assessment Program (eSNAP) Web-based tool using a framework of the Center for eHealth and Wellbeing Research (CeHRes) Roadmap for Web-based intervention development. The CeHRes Roadmap is still new in terms of tool development and we showcase an example of its application. OBJECTIVE: The aim of our study was to provide an example of the application of the Web-based intervention development process using the CeHRes Roadmap for other research teams to follow. In doing so, we are also sharing our pilot work to enhance eSNAP's acceptance and usability for users and the feasibility of its implementation. METHODS: We describe the development of the eSNAP app to support family caregivers of neuro-oncology patients. This development is based on the 5 iterative stages of the CeHRes Roadmap: contextual inquiry, value specification, design, operationalization, and summative evaluation. Research activities to support eSNAP development prior to implementation included literature review, focus groups, and iterative rounds of interviews. RESULTS: Key lessons learned in developing the eSNAP app broadly fell under a theme of translating theoretical needs and ideas to the real world. This included how to prioritize needs to be addressed at one time, how the modality of delivery may change design requirements, and how to develop a tool to fit within the context it will be used. CONCLUSIONS: Using the CeHRes Roadmap to develop Web-based interventions such as eSNAP helps to address potential issues by outlining important intervention development milestones. In addition, by encouraging inclusion of users and other stakeholders in the process, Web-based intervention developers using the Roadmap can identify what will work in the real world and increase feasibility and effectiveness.

An assessment of the screening method to evaluate vaccine effectiveness: the case of 7-valent pneumococcal conjugate vaccine in the United States.

The screening method, which employs readily available data, is an inexpensive and quick means of estimating vaccine effectiveness (VE). We compared estimates of effectiveness of heptavalent pneumococcal conjugate vaccine (PCV7) against invasive pneumococcal disease (IPD) using the screening and case-control methods. Cases were children aged 19-35 months with pneumococcus isolated from normally sterile sites residing in Active Bacterial Core surveillance areas in the United States. Case-control VE was estimated for 2001-2004 by comparing the odds of vaccination among cases and community controls. Screening-method VE for 2001-2009 was estimated by comparing the proportion of cases vaccinated to National Immunization Survey-derived coverage among the general population. To evaluate the plausibility of screening-method VE findings, we estimated attack rates among vaccinated and unvaccinated persons. We identified 1,154 children with IPD. Annual population PCV7 coverage with ≥1 dose increased from 38% to 97%. Case-control VE for ≥1 dose was estimated as 75% against all-serotype IPD (annual range: 35-83%) and 91% for PCV7-type IPD (annual range: 65-100%). By the screening method, the overall VE was 86% for ≥1 dose (annual range: -240-70%) against all-serotype IPD and 94% (annual range: 62-97%) against PCV7-type IPD. As cases of PCV7-type IPD declined during 2001-2005, estimated attack rates for all-serotype IPD among vaccinated and unvaccinated individuals became less consistent than what would be expected with the estimated effectiveness of PCV7. The screening method yields estimates of VE that are highly dependent on the time period during which it is used and the choice of outcome. The method should be used cautiously to evaluate VE of PCVs.

"It is good for my family's health and cooks food in a way that my heart loves": qualitative findings and implications for scaling up an improved cookstove project in rural Kenya.

The use of indoor, three-stone fire pits in resource-poor countries is a substantial burden on human health and the environment. We conducted a pilot intervention promoting the purchase and use of an improved cookstove in rural Kenya. The goals of this qualitative inquiry were to understand the motivation to purchase and use; perceived benefits and challenges of cookstove use; and the most influential promotion activities for scaling up future cookstove promotion. Purposive sampling was used to recruit 10 cookstove promoters and 30 cookstove purchasers in the Luo community. Qualitative semi-structured interviews were transcribed and a thematic analysis conducted. Women reported the need for less firewood, fuel cost savings, reduced smoke, improved cooking efficiency, reduced eye irritation, lung congestion and coughing as major benefits of the cookstove. Cost appeared to be a barrier to wider adoption. The most persuasive promotion strategies were interpersonal communication through social networks and cooking demonstrations. Despite this cost barrier, many women still considered the improved cookstove to be a great asset within their household. This inquiry provided important guidance for future cookstove implementation projects.

A strategy to increase adoption of locally-produced, ceramic cookstoves in rural Kenyan households.

BACKGROUND: Exposure to household air pollutants released during cooking has been linked to numerous adverse health outcomes among residents of rural areas in low-income countries. Improved cookstoves are one of few available interventions, but achieving equity in cookstove access has been challenging. Therefore, innovative approaches are needed. To evaluate a project designed to motivate adoption of locally-produced, ceramic cookstoves (upesi jiko) in an impoverished, rural African population, we assessed the perceived benefits of the cookstoves (in monetary and time-savings terms), the rate of cookstove adoption, and the equity of adoption. METHODS: The project was conducted in 60 rural Kenyan villages in 2008 and 2009. Baseline (n = 1250) and follow-up (n = 293) surveys and a stove-tracking database were analyzed. RESULTS: At baseline, nearly all respondents used wood (95%) and firepits (99%) for cooking; 98% desired smoke reductions. Households with upesi jiko subsequently spent <100 Kenyan Shillings/week on firewood more often (40%) than households without upesi jiko (20%) (p = 0.0002). There were no significant differences in the presence of children <2 years of age in households using upesi jiko (48%) or three-stone stoves (49%) (p = 0.88); children 2-5 years of age were less common in households using upesi jiko versus three-stone stoves (46% and 69%, respectively) (p = 0.0001). Vendors installed 1,124 upesi jiko in 757 multi-family households in 18 months; 68% of these transactions involved incentives for vendors and purchasers. Relatively few (<10%) upesi jiko were installed in households of women in the youngest age quartile (<22 years) or among households in the poorest quintile. CONCLUSIONS: Our strategy of training of local vendors, appropriate incentives, and product integration effectively accelerated cookstove adoption into a large number of households. The strategy also created opportunities to reinforce health messages and promote cookstoves sales and installation. However, the project's overall success was diminished by inequitable and incomplete adoption by households with the lowest socioeconomic status and young children present. Additional evaluations of similar strategies will be needed to determine whether our strategy can be applied equitably elsewhere, and whether reductions in fuel use, household air pollution, and the incidence of respiratory diseases will follow adoption of improved cookstoves.

Economic analysis of prevaccination serotesting compared with presumptive immunization for polio, diphtheria, and tetanus in internationally adopted and immigrant infants.

BACKGROUND: No consensus exists about whether to conduct prevaccination serotesting or to presumptively vaccinate internationally adopted and immigrant infants with inactivated polio (IPV) and diphtheria-tetanus-acellular pertussis (DTaP) immunizations. OBJECTIVE: To study the clinical and economic outcomes from a societal perspective of prevaccination serotesting in a hypothetical 12-month-old internationally adopted or immigrant infant. DESIGN AND METHODS: A decision analysis model was developed comparing presumptive vaccination with IPV versus serotesting for poliovirus type 1, 2, and 3 antibodies followed by vaccination in unprotected patients. A similar decision analysis model was developed comparing presumptive vaccination with DTaP versus serotesting for diphtheria and tetanus toxoid antibodies. The main outcome measures were cost per patient protected from polio, diphtheria, and tetanus. RESULTS: Compared with presumptive immunization, prevaccination serotesting for polio increases the cost per patient from $57 to $62 and decreases the percentage of patients protected against polio from 95.3% to 94.0%. Serotesting for diphtheria and tetanus increases the cost per patient from $62 to $119 and increases the percentage of patients protected against both diphtheria and tetanus from 91.5% to 92.3%. Presumptive immunization with DTaP costs less and is more clinically effective than serotesting if >80% of patients do not complete the full vaccine series or if antibody seroprevalence to both diphtheria and tetanus is <51%. CONCLUSIONS: Presumptive immunization for polio improves outcomes and saves costs compared with prevaccination serotesting in internationally adopted and immigrant infants. The results for DTaP are less definitive, although immunization is the preferred strategy in populations with poor vaccine compliance or low seroprevalence of antibodies to diphtheria and tetanus.