Economic analysis of antenatal screening for human T-cell lymphotropic virus type 1 in Brazil: an open access cost-utility model

Background Human T-cell lymphotropic virus type 1 (HTLV-1) is a retrovirus that causes severe diseases, such as aggressive cancer or progressive neurological disease. HTLV-1 affects mainly people in areas with low human development index and can be transmitted from mother to child, primarily through breastfeeding. Refraining from breastfeeding is an effective intervention to reduce the risk of infection in infants. However, HTLV-1 antenatal screening is not offered globally. According to WHO, the scarcity of cost-effectiveness studies is considered one of the major barriers to the implementation of policies to prevent HTLV-1 infection. Therefore, this study aimed to assess the cost-effectiveness of antenatal screening and postnatal interventions to prevent HTLV-1 mother-to-child transmission in Brazil and to develop an open-access, editable, mathematical model that can be used by other countries and regions to assess different scenarios. Methods In this cost-utility analysis, we constructed a decision tree and a Markov model to assess the cost-effectiveness of HTLV-1 antenatal screening and postnatal interventions (ie, avoidance of breastfeeding, by suppression of lactation with cabergoline, and provision of formula feed) to reduce transmission. For our model, we used data from Brazil and we took the perspective of the public health-care system to estimate costs. Findings The implementation of both screening and interventions would result in the prevention of 1039 infections in infants every year in Brazil with an incremental cost-effectiveness ratio (ICER) of US$11415 per quality-adjusted lifeyear (QALY). 88% of all probabilistic sensitivity analysis simulations had ICER values lower than the Brazilian costeffectiveness threshold ($18 107·74 per QALY). HTLV-1 prevalence in pregnant women, the risk of HTLV-1 transmission when breastfeeding lasts for 6 months or more, and the cost of screening tests were the variables with the largest effect on ICER. Interpretation HTLV-1 antenatal screening is cost-effective in Brazil. An open-access model was developed, and this tool could be used to assess the cost-effectiveness of such policy globally, favouring the implementation of interventions to prevent HTLV-1 mother-to-child transmission worldwide. (AU)

Avaliação clínica na atenção primária e infectologia dos pacientes com doença de chagas na forma crônica / Clinical assessment in primary and infectious disease care in patients with cardiac form of chagas diseases / Evaluación clínica en primaria y infecciosas de pacientes com enfermedad de las heridas crónicas en forma

A doença de chagas é a terceira doença parasitária mais prevalente no mundo e ocorre, muitas vezes, em indivíduos mais jovens, implicando em incapacidade, aposentadoria precoce e morte. O objetivo deste artigo é descrever alterações clínicas, laboratoriais, eletrocardiográficas e de bioimagem de pacientes com doença de Chagas na forma crônica cardíaca na atenção primária e infectologia. A metodologia adotada é o corte transversal, com análise retrospectiva de prontuários dos pacientes atendidos em ambulatórios de Clínica Médica e Infectologia de janeiro a dezembro de 2008. Os resultados apontam que os dados demográficosdos 21 pacientes foram: 57,1 por cento do sexo feminino; 42,9 por cento do sexo masculino; idade média de 58,5 anos; comorbidades 57,1 por cento. A maior parte apresentava a forma crônica cardíaca recente e leve (B1) baseada no Consenso Brasileiro de Doença de Chagas da Sociedade Brasileira de Medicina Tropical. As alterações mais frequentes no Eletrocardiograma foram: bloqueio do ramo direito, alteração de repolarização ventricular, bloqueio divisional anterossuperior esquerdo e bradicardia sinusal. Na radiografia de tórax, 35,3 por cento apresentaram aumento do índice cardiotorácico. Ao Ecocardiograma bidimensional com doppler foi observada uma fração de ejeção média de 66,7 por cento; 64,7 por cento deles apresentaram as seguintes alterações: disfunção diastólica de ventrículo esquerdo e insuficiência de válvula mitral. Ao comparar os pacientes com e sem comorbidades, foi observado que os achados dos exames complementares não apresentaram diferenças significativas entre os grupos. Concluiu-se que os pacientes com Doença de Chagas na forma crônica cardíaca leve apresentam idade mais avançada. Houve uma elevada porcentagem de comorbidades, podendo-se inferir que as alterações eletrocardiográficas, ecocardiográficas e radiográficas podem não sofrer influência das comorbidades.

Chagas disease is the third most prevalent parasitic disease in the world and it often occurs in younger individuals, resulting in disability, early retirement, and death. The aim of this study was to describe clinical, laboratory, electrocardiographic and bioimage changes in patients with Chronic Chagas heart disease. The methodology adopted is a cross-sectional study with retrospective analysis of records of patients from the infectious disease and parasitological hospitals centers, between January and December of 2008. The results indicate that the demographic data of 21 patients were: female (57.1 percent), male (42.9 percent), the average agewas 58.5 years, and 57.1 percent with co-morbidities. Most of the population studied had recent and/or mild chronic cardiac (B1) manifestations based on the Brazilian Consensus on Chagas disease from the Brazilian Society of Tropical Medicine. The most frequent changes in the electrocardiogram (ECG) were: Right bundle branch block (RBBB), ST-T changes, Left BundleBranch Block and Sinus Bradycardia. The most frequent change in chest radiography was the enlargementf cardiothoracic index (35.3 percent). Through the bidimensional echocardiography we observed an ejection fraction with 66.7 percent average and 64.7 percent of the patients presented the following changes: Left Ventricular Diastolic Dysfunction and Mitral Valve Insufficiency. When comparing the patients with and without co-morbidities, the findings of the electrocardiogram, echocardiogram and chest radiography, did not provide significant difference between thegroups. It can be concluded that the patients with heart Chagas disease patients presented a higher age. There was a high percentage of co- morbidities in the studied population and it can be inferred that the electrocardiographic, echocardiographic and radiographic changesmay not be impacted by the co-morbidities.

La enfermedad de Chagas es la tercera enfermedad parasitaria más frecuente en el mundo y, con frecuencia, afecyta a individuos más jóvenes, resultando en incapacidad, jubilación anticipada y la muerte. El objetivo de este artículo es describir alteraciones clínicas, de laboratorio, electrocardiográficas y de bioimagen de pacientes con enfermedad deChagas en su forma crónica cardiaca en la atención primaria e infectología. La metodología adoptada es de enfoque transversal con análisis retrospectiva de los históricos clínicos de los pacientes atendidos, de enero a diciembre de 2008, en una Clínica Médica ambulatorial y Enfermedades Infecciosas. Con relación a datos demográficos, los resultados muestran que de los 21 pacientes: 57,1 por ciento eran del sexo femenino, el 42,9 por ciento del sexo masculino con edad media de 58,5 años, y el 57,1 por ciento, co-mórbidos. Co base en el Consenso brasileñobasado en Enfermedad de Chagas de la Sociedad Brasileña de Medicina Tropical, la mayor parte presentaba la forma crónica cardiaca, reciente y leve (B1). Las alteraciones más frecuentes en el electrocardiograma fueron: bloqueo de la rama derecha, alteraciones de la repolarización ventricular, bloqueo divisional anterosuperior izquierdo y bradicardiasinusal.