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1.
BMC Health Serv Res ; 24(1): 104, 2024 Jan 18.
Artigo em Inglês | MEDLINE | ID: mdl-38238735

RESUMO

BACKGROUND: The vast region of northern Queensland (NQ) in Australia experiences poorer health outcomes and a disproportionate burden of communicable diseases compared with urban populations in Australia. This study examined the governance of COVID-19 surveillance and response in NQ to identify strengths and opportunities for improvement. METHODS: The manuscript presents an analysis of one case-unit within a broader case study project examining systems for surveillance and response for COVID-19 in NQ. Data were collected between October 2020-December 2021 comprising 47 interviews with clinical and public health staff, document review, and observation in organisational settings. Thematic analysis produced five key themes. RESULTS: Study findings highlight key strengths of the COVID-19 response, including rapid implementation of response measures, and the relative autonomy of NQ's Public Health Units to lead logistical decision-making. However, findings also highlight limitations and fragility of the public health system more generally, including unclear accountabilities, constraints on local community engagement, and workforce and other resourcing shortfalls. These were framed by state-wide regulatory and organisational incentives that prioritise clinical health care rather than disease prevention, health protection, and health promotion. Although NQ mobilised an effective COVID-19 response, findings suggest that NQ public health systems are marked by fragility, calling into question the region's preparedness for future pandemic events and other public health crises. CONCLUSIONS: Study findings highlight an urgent need to improve governance, resourcing, and political priority of public health in NQ to address unmet needs and ongoing threats.


Assuntos
COVID-19 , Humanos , COVID-19/epidemiologia , Saúde Pública , Queensland/epidemiologia , Hospitais , Austrália
2.
Trop Med Infect Dis ; 7(9)2022 Sep 19.
Artigo em Inglês | MEDLINE | ID: mdl-36136662

RESUMO

The international border between Australia and Papua New Guinea (PNG) serves as a gateway for the delivery of primary and tertiary healthcare for PNG patients presenting to Australian health facilities with presumptive tuberculosis (TB). An audit of all PNG nationals with presumptive TB who presented to clinics in the Torres Strait between 2016 and 2019 was conducted to evaluate outcomes for PNG patients and to consider the consistency and equity of decision-making regarding aeromedical evacuation. We also reviewed the current aeromedical retrieval policy and the outcomes of patients referred back to Daru General Hospital in PNG. During the study period, 213 PNG nationals presented with presumptive TB to primary health centres (PHC) in the Torres Strait. In total, 44 (21%) patients were medically evacuated to Australian hospitals; 26 met the evacuation criteria of whom 3 died, and 18 did not meet the criteria of whom 1 died. A further 22 patients who met the medical evacuation criteria into Australia were referred to Daru General Hospital of whom 2 died and 10 were lost to follow-up. The cross-border movement of people from PNG into Australia is associated with an emergent duty of care. Ongoing monitoring and evaluation of patient outcomes are necessary for transparency and justice.

3.
Am J Epidemiol ; 191(2): 255-270, 2022 01 24.
Artigo em Inglês | MEDLINE | ID: mdl-34017976

RESUMO

Many tuberculosis (TB) cases in low-incidence settings are attributed to reactivation of latent TB infection (LTBI) acquired overseas. We assessed the cost-effectiveness of community-based LTBI screening and treatment strategies in recent migrants to a low-incidence setting (Australia). A decision-analytical Markov model was developed that cycled 1 migrant cohort (≥11-year-olds) annually over a lifetime from 2020. Postmigration/onshore and offshore (screening during visa application) strategies were compared with existing policy (chest x-ray during visa application). Outcomes included TB cases averted and discounted cost per quality-adjusted life-year (QALY) gained from a health-sector perspective. Most recent migrants are young adults and cost-effectiveness is limited by their relatively low LTBI prevalence, low TB mortality risks, and high emigration probability. Onshore strategies cost at least $203,188 (Australian) per QALY gained, preventing approximately 2.3%-7.0% of TB cases in the cohort. Offshore strategies (screening costs incurred by migrants) cost at least $13,907 per QALY gained, preventing 5.5%-16.9% of cases. Findings were most sensitive to the LTBI treatment quality-of-life decrement (further to severe adverse events); with a minimal decrement, all strategies caused more ill health than they prevented. Additional LTBI strategies in recent migrants could only marginally contribute to TB elimination and are unlikely to be cost-effective unless screening costs are borne by migrants and potential LTBI treatment quality-of-life decrements are ignored.


Assuntos
Antituberculosos/economia , Tuberculose Latente/economia , Tuberculose Latente/epidemiologia , Programas de Rastreamento/economia , Migrantes/estatística & dados numéricos , Adolescente , Adulto , Austrália/epidemiologia , Criança , Análise Custo-Benefício , Feminino , Humanos , Incidência , Tuberculose Latente/tratamento farmacológico , Masculino , Programas de Rastreamento/métodos , Pessoa de Meia-Idade , Prevalência , Anos de Vida Ajustados por Qualidade de Vida , Adulto Jovem
5.
Epidemics ; 36: 100470, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34052666

RESUMO

Tuberculosis (TB) exhibits considerable spatial heterogeneity, occurring in clusters that may act as hubs of community transmission. We evaluated the impact of an intervention targeting spatial TB hotspots in a rural region of Ethiopia. To evaluate the impact of targeted active case finding (ACF), we used a spatially structured mathematical model that has previously been described. From model equilibrium, we simulated the impact of a hotspot-targeted strategy (HTS) on TB incidence ten years from intervention commencement and the associated cost-effectiveness. HTS was also compared with an untargeted strategy (UTS). We used logistic cost-coverage analysis to estimate cost-effectiveness of interventions. At a community screening coverage level of 95 % in a hotspot region, which corresponds to screening 20 % of the total population, HTS would reduce overall TB incidence by 52 % compared with baseline. For UTS to achieve an equivalent effect, it would be necessary to screen more than 80 % of the total population. Compared to the existing passive case detection strategy, the HTS at a CDR of 75 percent in hotspot regions is expected to avert 1,023 new TB cases over ten years saving USD 170 per averted case. Similarly, at the same CDR, the UTS will detect 1316 cases over the same period saving USD 3 per averted TB case. The incremental-cost effectiveness-ratio (ICER) of UTS compared with HTS is USD 582 per averted case corresponding to 293 more TB cases averted at an additional cost of USD 170,700. Where regional TB program spending was capped at current levels, maximum gains in incidence reduction were seen when the regional budget was shared between hotspots and non-hotspot regions in the ratio of 40% : 60%. Our analysis suggests that a spatially targeted strategy is efficient and cost-saving, with the potential for significant reduction in overall TB burden.


Assuntos
Tuberculose , Análise por Conglomerados , Análise Custo-Benefício , Etiópia/epidemiologia , Humanos , Políticas , Tuberculose/epidemiologia , Tuberculose/prevenção & controle
6.
Paediatr Respir Rev ; 35: 57-60, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32690354

RESUMO

Models have played an important role in policy development to address the COVID-19 outbreak from its emergence in China to the current global pandemic. Early projections of international spread influenced travel restrictions and border closures. Model projections based on the virus's infectiousness demonstrated its pandemic potential, which guided the global response to and prepared countries for increases in hospitalisations and deaths. Tracking the impact of distancing and movement policies and behaviour changes has been critical in evaluating these decisions. Models have provided insights into the epidemiological differences between higher and lower income countries, as well as vulnerable population groups within countries to help design fit-for-purpose policies. Economic evaluation and policies have combined epidemic models and traditional economic models to address the economic consequences of COVID-19, which have informed policy calls for easing restrictions. Social contact and mobility models have allowed evaluation of the pathways to safely relax mobility restrictions and distancing measures. Finally, models can consider future end-game scenarios, including how suppression can be achieved and the impact of different vaccination strategies.


Assuntos
Infecções por Coronavirus/epidemiologia , Política de Saúde , Modelos Teóricos , Pneumonia Viral/epidemiologia , Formulação de Políticas , Betacoronavirus , COVID-19 , Vacinas contra COVID-19 , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Países em Desenvolvimento , Métodos Epidemiológicos , Humanos , Modelos Econômicos , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Saúde Pública , Política Pública , SARS-CoV-2 , Viagem , Vacinas Virais/uso terapêutico
7.
Front Public Health ; 8: 241, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32574307

RESUMO

COVID-19 is not only a global pandemic and public health crisis; it has also severely affected the global economy and financial markets. Significant reductions in income, a rise in unemployment, and disruptions in the transportation, service, and manufacturing industries are among the consequences of the disease mitigation measures that have been implemented in many countries. It has become clear that most governments in the world underestimated the risks of rapid COVID-19 spread and were mostly reactive in their crisis response. As disease outbreaks are not likely to disappear in the near future, proactive international actions are required to not only save lives but also protect economic prosperity.


Assuntos
COVID-19/economia , Defesa Civil , Surtos de Doenças/economia , Internacionalidade , Saúde Pública/economia , Humanos , SARS-CoV-2 , Desemprego
8.
Sci Rep ; 9(1): 12720, 2019 09 03.
Artigo em Inglês | MEDLINE | ID: mdl-31481739

RESUMO

Tuberculosis (TB) is a potentially fatal infectious disease that continues to be a public health problem in Bangladesh. Each year in Bangladesh an estimated 70,000 people die of TB and 300,000 new cases are projected. It is important to understand the association between TB incidence and weather factors in Bangladesh in order to develop proper intervention programs. In this study, we examine the delayed effect of weather variables on TB occurrence and estimate the burden of the disease that can be attributed to weather factors. We used generalized linear Poisson regression models to investigate the association between weather factors and TB cases reported to the Bangladesh National TB control program between 2007 and 2012 in three known endemic districts of North-East Bangladesh. The associated risk of TB in the three districts increases with prolonged exposure to temperature and rainfall, and persisted at lag periods beyond 6 quarters. The association between humidity and TB is strong and immediate at low humidity, but the risk decreases with increasing lag. Using the optimum weather values corresponding to the lowest risk of infection, the risk of TB is highest at low temperature, low humidity and low rainfall. Measures of the risk attributable to weather variables revealed that weather-TB cases attributed to humidity is higher than that of temperature and rainfall in each of the three districts. Our results highlight the high linearity of temporal lagged effects and magnitudes of the burden attributable to temperature, humidity, and rainfall on TB endemics. The results can hopefully advise the Bangladesh National TB control program and act as a practical reference for the early warning of TB cases.


Assuntos
Efeitos Psicossociais da Doença , Epidemias , Umidade , Chuva , Tuberculose/epidemiologia , Bangladesh/epidemiologia , Feminino , Humanos , Incidência , Masculino
9.
BMC Infect Dis ; 19(1): 474, 2019 May 28.
Artigo em Inglês | MEDLINE | ID: mdl-31138129

RESUMO

BACKGROUND: Tuberculosis (TB) is the leading cause of death from an infectious disease in Ethiopia, killing more than 30 thousand people every year. This study aimed to determine whether the rates of poor TB treatment outcome varied geographically across Ethiopia at district and zone levels and whether such variability was associated with socioeconomic, behavioural, health care access, or climatic conditions. METHODS: A geospatial analysis was conducted using national TB data reported to the health management information system (HMIS), for the period 2015-2017. The prevalence of poor TB treatment outcomes was calculated by dividing the sum of treatment failure, death and loss to follow-up by the total number of TB patients. Binomial logistic regression models were computed and a spatial analysis was performed using a Bayesian framework. Estimates of parameters were generated using Markov chain Monte Carlo (MCMC) simulation. Geographic clustering was assessed using the Getis-Ord Gi* statistic, and global and local Moran's I statistics. RESULTS: A total of 223,244 TB patients were reported from 722 districts in Ethiopia during the study period. Of these, 63,556 (28.5%) were cured, 139,633 (62.4%) completed treatment, 6716 (3.0%) died, 1459 (0.7%) had treatment failure, and 12,200 (5.5%) were lost to follow-up. The overall prevalence of a poor TB treatment outcome was 9.0% (range, 1-58%). Hot-spots and clustering of poor TB treatment outcomes were detected in districts near the international borders in Afar, Gambelia, and Somali regions and cold spots were detected in Oromia and Amhara regions. Spatial clustering of poor TB treatment outcomes was positively associated with the proportion of the population with low wealth index (OR: 1.01; 95%CI: 1.0, 1.01), the proportion of the population with poor knowledge about TB (OR: 1.02; 95%CI: 1.01, 1.03), and higher annual mean temperature per degree Celsius (OR: 1.15; 95% CI: 1.08, 1.21). CONCLUSIONS: This study showed significant spatial variation in poor TB treatment outcomes in Ethiopia that was related to underlying socioeconomic status, knowledge about TB, and climatic conditions. Clinical and public health interventions should be targeted in hot spot areas to reduce poor TB treatment outcomes and to achieve the national End-TB Strategy targets.


Assuntos
Tuberculose/tratamento farmacológico , Tuberculose/epidemiologia , Adolescente , Adulto , Idoso , Teorema de Bayes , Análise por Conglomerados , Etiópia/epidemiologia , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Acessibilidade aos Serviços de Saúde , Humanos , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Método de Monte Carlo , Prevalência , Fatores Socioeconômicos , Análise Espacial , Resultado do Tratamento
10.
J Antimicrob Chemother ; 74(1): 218-227, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30295760

RESUMO

Background: Latent tuberculosis infection (LTBI) is a critical driver of the global burden of active TB, and therefore LTBI treatment is key for TB elimination. Treatment regimens for LTBI include self-administered daily isoniazid for 6 (6H) or 9 (9H) months, self-administered daily rifampicin plus isoniazid for 3 months (3RH), self-administered daily rifampicin for 4 months (4R) and weekly rifapentine plus isoniazid for 3 months self-administered (3HP-SAT) or administered by a healthcare worker as directly observed therapy (3HP-DOT). Data on the relative cost-effectiveness of these regimens are needed to assist policymakers and clinicians in selecting an LTBI regimen. Objectives: To evaluate the cost-effectiveness of all regimens for treating LTBI. Methods: We developed a Markov model to investigate the cost-effectiveness of 3HP-DOT, 3HP-SAT, 4R, 3RH, 9H and 6H for LTBI treatment in a cohort of 10000 adults with LTBI. Cost-effectiveness was evaluated from a health system perspective over a 20 year time horizon. Results: Compared with no preventive treatment, 3HP-DOT, 3HP-SAT, 4R, 3RH, 9H and 6H prevented 496, 470, 442, 418, 370 and 276 additional cases of active TB per 10000 patients, respectively. All regimens reduced costs and increased QALYs compared with no preventive treatment. 3HP was more cost-effective under DOT than under SAT at a cost of US$27948 per QALY gained. Conclusions: Three months of weekly rifapentine plus isoniazid is more cost-effective than other regimens. Greater recognition of the benefits of short-course regimens can contribute to the scale-up of prevention and achieving the 'End TB' targets.


Assuntos
Antituberculosos/administração & dosagem , Análise Custo-Benefício , Isoniazida/administração & dosagem , Tuberculose Latente/tratamento farmacológico , Rifampina/análogos & derivados , Adolescente , Adulto , Idoso , Antituberculosos/economia , Técnicas de Apoio para a Decisão , Quimioterapia Combinada/economia , Quimioterapia Combinada/métodos , Feminino , Custos de Cuidados de Saúde , Humanos , Isoniazida/economia , Tuberculose Latente/economia , Masculino , Pessoa de Meia-Idade , Rifampina/administração & dosagem , Rifampina/economia , Adulto Jovem
11.
BMC Infect Dis ; 18(1): 511, 2018 Oct 11.
Artigo em Inglês | MEDLINE | ID: mdl-30309313

RESUMO

BACKGROUND: Clinical studies and mathematical simulation suggest that active surveillance with contact isolation is associated with reduced vancomycin-resistant enterococci (VRE) prevalence compared to passive surveillance. Models using pre- and post-intervention data that account for the imperfect observation and serial dependence of VRE transmission events can better estimate the effectiveness of active surveillance and subsequent contact isolation; however, such analyses have not been performed. METHODS: A mathematical model was fitted to surveillance data collected pre- and post-implementation of active surveillance with contact isolation in the haematology-oncology ward. We developed a Hidden Markov Model to describe undetected and observed VRE colonisation/infection status based on the detection activities in the ward. Bayesian inference was used to estimate transmission rates. The effectiveness of active surveillance was assumed to be via increased detection and subsequent contact isolation of VRE positive patients. RESULTS: We estimated that 31% (95% credible interval: 0.33-85%) of the VRE transmissions were due to cross-transmission between patients. The ratio of transmission rates from patients with contact isolation versus those without contact isolation was 0.33 (95% credible interval: 0.050-1.22). CONCLUSIONS: The majority of the VRE acquisitions in the haematology-oncology ward was estimated to be due to background rates of VRE, rather than within ward patient to patient acquisition. The credible interval for cross-transmission was wide which results in a large degree of uncertainty in the estimates. Factors that could account for background VRE acquisition include endogenous acquisition from antibiotic selection pressure and VRE in the environment. Contact isolation was not significantly associated with reduced VRE transmission in settings where the majority of VRE acquisition was due to background acquisition, emphasising the need to identify and address the source of acquisition. As the credible interval for the ratio of VRE transmission in contact isolated versus non-contact isolated patients crossed 1, there is a probability that the transmission rate in contact isolation was not lower. Our finding highlights the need to optimise infection control measures other than active surveillance for VRE and subsequent contact isolation to reduce VRE transmission. Such measures could include antimicrobial stewardship, environmental cleaning, and hand hygiene.


Assuntos
Infecções por Bactérias Gram-Positivas/transmissão , Modelos Teóricos , Enterococos Resistentes à Vancomicina/isolamento & purificação , Teorema de Bayes , Infecções por Bactérias Gram-Positivas/epidemiologia , Infecções por Bactérias Gram-Positivas/microbiologia , Humanos , Cadeias de Markov , Enterococos Resistentes à Vancomicina/patogenicidade
12.
Geospat Health ; 12(2): 575, 2017 11 27.
Artigo em Inglês | MEDLINE | ID: mdl-29239568

RESUMO

The burden of tuberculosis (TB) in children reflects continuing and recent transmission within a population. This study aimed to identify spatiotemporal and socio-climatic factors associated with paediatric TB in north-western Ethiopia. Multivariate Poisson regression models were computed using a Bayesian framework. Estimates of parameters were generated using Markov chain Monte Carlo simulation. A total of 2,240 children aged under 15 years diagnosed with TB during the years 2013- 2016 were included in the analysis. The annual TB incidence rates were 44 and 28 per 100,000 children, for children aged under 15 and 5 years, respectively. Spatial clustering of TB was observed in the border area of north-western Ethiopia. The spatio-temporal transmission of childhood TB was found to be associated with district level socio-climatic factors such as urbanisation [relative risk (RR): 1.8; 95% credible interval (CrI): 1.2, 2.6], lower educational status (RR: 1.5; 95% CrI: 1.0, 2.1), a high percentage of internal migration (RR: 1.3; 95% CrI: 1.0, 1.6), high temperature (RR: 1.3; 95% CrI: 1.0, 1.7) and high rainfall (RR: 1.5; 95% CrI: 1.1, 2.0). We conclude that interventions targeting hotspot districts with a high proportion of childhood TB are important to reduce TB transmission in northwest Ethiopia.


Assuntos
Análise Espaço-Temporal , Tuberculose/epidemiologia , Adolescente , Teorema de Bayes , Criança , Pré-Escolar , Emigração e Imigração , Etiópia/epidemiologia , Feminino , Humanos , Lactente , Masculino , Cadeias de Markov , Método de Monte Carlo , Fatores Socioeconômicos , Temperatura , Urbanização
13.
Intern Med J ; 47(12): 1433-1436, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29224209

RESUMO

BACKGROUND: Currently, treatment of latent tuberculosis infection (LTBI) in Australia consists most commonly of a 9-month course of isoniazid (9H). A 3-month course of weekly isoniazid and rifapentine (3HP) has been shown to be as effective as 9 months of daily isoniazid, and associated with less hepatotoxicity; however, rifapentine is not currently available in Australia. Introduction of this regimen would have apparent advantages for people with LTBI in Victoria by safely shortening duration of LTBI therapy. However, the cost benefit of this new therapeutic approach is uncertain. AIM: Cost-analysis of standard and short-course therapy for LTBI in an Australian context. METHODS: Single-centre randomised controlled trial conducted between December 2013-March 2016. Participants underwent 1:1 randomisation to either a 9-month course of daily isoniazid or a 12-week course of weekly isoniazid and rifapentine. The primary outcome measure was total healthcare system costs (in Australian dollars; AUD) per completed course of LTBI therapy. Secondary cost analyses were performed to consider varying assumptions regarding commercial cost of rifapentine. RESULTS: Overall, 34 of 40 (85%) participants in the 9H group and 36/40 (90%) in the 3HR group completed therapy. One patient in the 3HP group was hospitalised for a febrile illness; no hospitalisations were recorded in the 9H group. The cost per completed course of 9H was 601 AUD, while that of 3HP was significantly lower at 511 AUD (P < 0.01). CONCLUSIONS: This study provides cost analysis evidence to support the use of 3HP for the treatment of LTBI in Australia.


Assuntos
Antituberculosos/economia , Análise Custo-Benefício/métodos , Erradicação de Doenças/métodos , Isoniazida/economia , Tuberculose Latente/economia , Rifampina/análogos & derivados , Adolescente , Adulto , Idoso , Antibióticos Antituberculose/administração & dosagem , Antibióticos Antituberculose/economia , Antituberculosos/administração & dosagem , Austrália , Esquema de Medicação , Feminino , Humanos , Isoniazida/administração & dosagem , Tuberculose Latente/tratamento farmacológico , Tuberculose Latente/epidemiologia , Masculino , Pessoa de Meia-Idade , Nova Zelândia/epidemiologia , Estudos Prospectivos , Rifampina/administração & dosagem , Rifampina/economia , Autoadministração , Adulto Jovem
14.
PLoS One ; 12(2): e0171800, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28182726

RESUMO

BACKGROUND: Understanding the geographical distribution of multidrug-resistant tuberculosis (MDR-TB) in high TB burden countries such as Ethiopia is crucial for effective control of TB epidemics in these countries, and thus globally. We present the first spatial analysis of multidrug resistant tuberculosis, and its relationship to socio-economic, demographic and household factors in northwest Ethiopia. METHODS: An ecological study was conducted using data on patients diagnosed with MDR-TB at the University of Gondar Hospital MDR-TB treatment centre, for the period 2010 to 2015. District level population data were extracted from the Ethiopia National and Regional Census Report. Spatial autocorrelation was explored using Moran's I statistic, Local Indicators of Spatial Association (LISA), and the Getis-Ord statistics. A multivariate Poisson regression model was developed with a conditional autoregressive (CAR) prior structure, and with posterior parameters estimated using a Bayesian Markov chain Monte Carlo (MCMC) simulation approach with Gibbs sampling, in WinBUGS. RESULTS: A total of 264 MDR-TB patients were included in the analysis. The overall crude incidence rate of MDR-TB for the six-year period was 3.0 cases per 100,000 population. The highest incidence rate was observed in Metema (21 cases per 100,000 population) and Humera (18 cases per 100,000 population) districts; whereas nine districts had zero cases. Spatial clustering of MDR-TB was observed in districts located in the Ethiopia-Sudan and Ethiopia-Eritrea border regions, where large numbers of seasonal migrants live. Spatial clustering of MDR-TB was positively associated with urbanization (RR: 1.02; 95%CI: 1.01, 1.04) and the percentage of men (RR: 1.58; 95% CI: 1.26, 1.99) in the districts; after accounting for these factors there was no residual spatial clustering. CONCLUSION: Spatial clustering of MDR-TB, fully explained by demographic factors (urbanization and percent male), was detected in the border regions of northwest Ethiopia, in locations where seasonal migrants live and work. Cross-border initiatives including options for mobile TB treatment and follow up are important for the effective control of MDR-TB in the region.


Assuntos
Características da Família , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Adulto , Antituberculosos/uso terapêutico , Teorema de Bayes , Demografia , Etiópia/epidemiologia , Feminino , Humanos , Incidência , Masculino , Fatores Socioeconômicos , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , População Urbana/estatística & dados numéricos
15.
Gut ; 66(8): 1507-1515, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-27196586

RESUMO

AIMS: The WHO's draft HCV elimination targets propose an 80% reduction in incidence and a 65% reduction in HCV-related deaths by 2030. We estimate the treatment scale-up required and cost-effectiveness of reaching these targets among injecting drug use (IDU)-acquired infections using Australian disease estimates. METHODS: A mathematical model of HCV transmission, liver disease progression and treatment among current and former people who inject drugs (PWID). Treatment scale-up and the most efficient allocation to priority groups (PWID or patients with advanced liver disease) were determined; total healthcare and treatment costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) compared with inaction were calculated. RESULTS: 5662 (95% CI 5202 to 6901) courses per year (30/1000 IDU-acquired infections) were required, prioritised to patients with advanced liver disease, to reach the mortality target. 4725 (3278-8420) courses per year (59/1000 PWID) were required, prioritised to PWID, to reach the incidence target; this also achieved the mortality target, but to avoid clinically unacceptable HCV-related deaths an additional 5564 (1959-6917) treatments per year (30/1000 IDU-acquired infections) were required for 5 years for patients with advanced liver disease. Achieving both targets in this way cost $A4.6 ($A4.2-$A4.9) billion more than inaction, but gained 184 000 (119 000-417 000) QALYs, giving an ICER of $A25 121 ($A11 062-$A39 036) per QALY gained. CONCLUSIONS: Achieving WHO elimination targets with treatment scale-up is likely to be cost-effective, based on Australian HCV burden and demographics. Reducing incidence should be a priority to achieve both WHO elimination goals in the long-term.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Hepatite C/economia , Hepatite C/epidemiologia , Abuso de Substâncias por Via Intravenosa/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Austrália/epidemiologia , Análise Custo-Benefício , Saúde Global , Objetivos , Redução do Dano , Hepatite C/tratamento farmacológico , Hepatite C/prevenção & controle , Humanos , Incidência , Pessoa de Meia-Idade , Modelos Econômicos , Prevalência , Anos de Vida Ajustados por Qualidade de Vida , Organização Mundial da Saúde , Adulto Jovem
16.
Lancet Glob Health ; 4(11): e816-e826, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27720689

RESUMO

BACKGROUND: The post-2015 End TB Strategy sets global targets of reducing tuberculosis incidence by 50% and mortality by 75% by 2025. We aimed to assess resource requirements and cost-effectiveness of strategies to achieve these targets in China, India, and South Africa. METHODS: We examined intervention scenarios developed in consultation with country stakeholders, which scaled up existing interventions to high but feasible coverage by 2025. Nine independent modelling groups collaborated to estimate policy outcomes, and we estimated the cost of each scenario by synthesising service use estimates, empirical cost data, and expert opinion on implementation strategies. We estimated health effects (ie, disability-adjusted life-years averted) and resource implications for 2016-35, including patient-incurred costs. To assess resource requirements and cost-effectiveness, we compared scenarios with a base case representing continued current practice. FINDINGS: Incremental tuberculosis service costs differed by scenario and country, and in some cases they more than doubled existing funding needs. In general, expansion of tuberculosis services substantially reduced patient-incurred costs and, in India and China, produced net cost savings for most interventions under a societal perspective. In all three countries, expansion of access to care produced substantial health gains. Compared with current practice and conventional cost-effectiveness thresholds, most intervention approaches seemed highly cost-effective. INTERPRETATION: Expansion of tuberculosis services seems cost-effective for high-burden countries and could generate substantial health and economic benefits for patients, although substantial new funding would be required. Further work to determine the optimal intervention mix for each country is necessary. FUNDING: Bill & Melinda Gates Foundation.


Assuntos
Análise Custo-Benefício , Atenção à Saúde , Custos de Cuidados de Saúde , Recursos em Saúde , Necessidades e Demandas de Serviços de Saúde , Anos de Vida Ajustados por Qualidade de Vida , Tuberculose/prevenção & controle , China , Atenção à Saúde/economia , Previsões , Objetivos , Gastos em Saúde , Política de Saúde , Acessibilidade aos Serviços de Saúde , Humanos , Índia , Modelos Teóricos , Aceitação pelo Paciente de Cuidados de Saúde , África do Sul , Tuberculose/economia , Tuberculose/mortalidade
17.
PLoS Negl Trop Dis ; 10(9): e0005018, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27661978

RESUMO

BACKGROUND: Effective response to emerging infectious disease (EID) threats relies on health care systems that can detect and contain localised outbreaks before they reach a national or international scale. The Asia-Pacific region contains low and middle income countries in which the risk of EID outbreaks is elevated and whose health care systems may require international support to effectively detect and respond to such events. The absence of comprehensive data on populations, health care systems and disease characteristics in this region makes risk assessment and decisions about the provision of such support challenging. METHODOLOGY/PRINCIPAL FINDINGS: We describe a mathematical modelling framework that can inform this process by integrating available data sources, systematically explore the effects of uncertainty, and provide estimates of outbreak risk under a range of intervention scenarios. We illustrate the use of this framework in the context of a potential importation of Ebola Virus Disease into the Asia-Pacific region. Results suggest that, across a wide range of plausible scenarios, preemptive interventions supporting the timely detection of early cases provide substantially greater reductions in the probability of large outbreaks than interventions that support health care system capacity after an outbreak has commenced. CONCLUSIONS/SIGNIFICANCE: Our study demonstrates how, in the presence of substantial uncertainty about health care system infrastructure and other relevant aspects of disease control, mathematical models can be used to assess the constraints that limited resources place upon the ability of local health care systems to detect and respond to EID outbreaks in a timely and effective fashion. Our framework can help evaluate the relative impact of these constraints to identify resourcing priorities for health care system support, in order to inform principled and quantifiable decision making.

18.
Am J Epidemiol ; 183(12): 1138-48, 2016 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-27199387

RESUMO

Tuberculosis (TB) and multidrug-resistant TB (MDR-TB) are major health problems in Western Province, Papua New Guinea. While comprehensive expansion of TB control programs is desirable, logistical challenges are considerable, and there is substantial uncertainty regarding the true disease burden. We parameterized our previously described mathematical model of Mycobacterium tuberculosis dynamics in Western Province, following an epidemiologic assessment. Five hypothetical scenarios representing alternative programmatic approaches during the period from 2013 to 2023 were developed with local staff. Bayesian uncertainty analyses were undertaken to explicitly acknowledge the uncertainty around key epidemiologic parameters, and an economic evaluation was performed. With continuation of existing programmatic strategies, overall TB incidence remained stable at 555 cases per 100,000 population per year (95% simulation interval (SI): 420, 807), but the proportion of incident cases attributable to MDR-TB increased from 16% to 35%. Comprehensive, provincewide strengthening of existing programs reduced incidence to 353 cases per 100,000 population per year (95% SI: 246, 558), with 46% being cases of MDR-TB, while incorporating programmatic management of MDR-TB into these programs reduced incidence to 233 cases per 100,000 population per year (95% SI: 198, 269) with 14% MDR-TB. Most economic costs were due to hospitalization during the intensive treatment phase. Broad scale-up of TB control activities in Western Province with incorporation of programmatic management of MDR-TB is vital if control is to be achieved. Community-based treatment approaches are important to reduce the associated economic costs.


Assuntos
Controle de Doenças Transmissíveis/estatística & dados numéricos , Mycobacterium tuberculosis , Tuberculose/economia , Tuberculose/epidemiologia , Antituberculosos/economia , Antituberculosos/uso terapêutico , Teorema de Bayes , Terapia Diretamente Observada/economia , Terapia Diretamente Observada/estatística & dados numéricos , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Modelos Teóricos , Papua Nova Guiné/epidemiologia , Tuberculose/terapia , Tuberculose Resistente a Múltiplos Medicamentos/economia , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Tuberculose Resistente a Múltiplos Medicamentos/terapia
19.
PLoS One ; 10(7): e0132037, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26131722

RESUMO

Little is known about the transmission dynamics of Acinetobacter baumannii in hospitals, despite such information being critical for designing effective infection control measures. In the absence of comprehensive epidemiological data, mathematical modelling is an attractive approach to understanding transmission process. The statistical challenge in estimating transmission parameters from infection data arises from the fact that most patients are colonised asymptomatically and therefore the transmission process is not fully observed. Hidden Markov models (HMMs) can overcome this problem. We developed a continuous-time structured HMM to characterise the transmission dynamics, and to quantify the relative importance of different acquisition sources of A. baumannii in intensive care units (ICUs) in three hospitals in Melbourne, Australia. The hidden states were the total number of patients colonised with A. baumannii (both detected and undetected). The model input was monthly incidence data of the number of detected colonised patients (observations). A Bayesian framework with Markov chain Monte Carlo algorithm was used for parameter estimations. We estimated that 96-98% of acquisition in Hospital 1 and 3 was due to cross-transmission between patients; whereas most colonisation in Hospital 2 was due to other sources (sporadic acquisition). On average, it takes 20 and 31 days for each susceptible individual in Hospital 1 and Hospital 3 to become colonised as a result of cross-transmission, respectively; whereas it takes 17 days to observe one new colonisation from sporadic acquisition in Hospital 2. The basic reproduction ratio (R0) for Hospital 1, 2 and 3 was 1.5, 0.02 and 1.6, respectively. Our study is the first to characterise the transmission dynamics of A. baumannii using mathematical modelling. We showed that HMMs can be applied to sparse hospital infection data to estimate transmission parameters despite unobserved events and imperfect detection of the organism. Our results highlight the need to optimise infection control in ICUs.


Assuntos
Infecções por Acinetobacter/transmissão , Acinetobacter baumannii/isolamento & purificação , Infecção Hospitalar/transmissão , Surtos de Doenças , Unidades de Terapia Intensiva , Cadeias de Markov , Modelos Teóricos , Infecções por Acinetobacter/epidemiologia , Infecções por Acinetobacter/prevenção & controle , Teorema de Bayes , Portador Sadio/epidemiologia , Portador Sadio/microbiologia , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/microbiologia , Infecção Hospitalar/prevenção & controle , Surtos de Doenças/prevenção & controle , Higiene das Mãos , Número de Leitos em Hospital , Humanos , Controle de Infecções/métodos , Infectologia , Método de Monte Carlo , Roupa de Proteção , Gestão da Segurança , Precauções Universais , Vitória/epidemiologia
20.
PLoS One ; 9(9): e108610, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25268809

RESUMO

OBJECTIVES: Refugees and immigrants from developing countries settling in industrialised countries have a high prevalence of Helicobacter pylori (H. pylori). Screening these groups for H. pylori and use of eradication therapy to reduce the future burden of gastric cancer and peptic ulcer disease is not currently recommended in most countries. We investigated whether a screening and eradication approach would be cost effective in high prevalence populations. METHODS: Nine different screening and follow-up strategies for asymptomatic immigrants from high H. pylori prevalence areas were compared with the current approach of no screening. Cost effectiveness comparisons assumed population prevalence's of H. pylori of 25%, 50% or 75%. The main outcome measure was the net cost for each cancer prevented for each strategy. Total costs of each strategy and net costs including savings from reductions in ulcers and gastric cancer were also calculated. RESULTS: Stool antigen testing with repeat testing after treatment was the most cost effective approach relative to others, for each prevalence value. The net cost per cancer prevented with this strategy was US$111,800 (assuming 75% prevalence), $132,300 (50%) and $193,900 (25%). A test and treat strategy using stool antigen remained relatively cost effective, even when the prevalence was 25%. CONCLUSIONS: H. pylori screening and eradication can be an effective strategy for reducing rates of gastric cancer and peptic ulcers in high prevalence populations and our data suggest that use of stool antigen testing is the most cost effective approach.


Assuntos
Antígenos de Bactérias/análise , Emigrantes e Imigrantes , Infecções por Helicobacter/diagnóstico , Programas de Rastreamento/economia , Modelos Estatísticos , Úlcera Péptica/economia , Neoplasias Gástricas/economia , Austrália , Efeitos Psicossociais da Doença , Análise Custo-Benefício , Países em Desenvolvimento , Fezes/microbiologia , Infecções por Helicobacter/complicações , Infecções por Helicobacter/microbiologia , Helicobacter pylori/imunologia , Helicobacter pylori/isolamento & purificação , Humanos , Úlcera Péptica/etiologia , Úlcera Péptica/microbiologia , Úlcera Péptica/prevenção & controle , Prevalência , Refugiados , Neoplasias Gástricas/etiologia , Neoplasias Gástricas/microbiologia , Neoplasias Gástricas/prevenção & controle
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