Cost-effectiveness analysis of surgical masks, N95 masks compared to wearing no mask for the prevention of COVID-19 among health care workers: Evidence from the public health care setting in India.

BACKGROUND: Nonpharmacological interventions, such as personal protective equipment for example, surgical masks and respirators, and maintenance of hand hygiene along with COVID-19 vaccines have been recommended to reduce viral transmission in the community and health care settings. There is evidence from the literature that surgical and N95 masks may reduce the initial degree of exposure to the virus. A limited research that has studied the cost-effective analysis of surgical masks and N95 masks among health care workers in the prevention of COVID-19 in India. The objective of this study was to estimate the cost-effectiveness of N95 and surgical mask compared to wearing no mask in public hospital settings for preventing COVID-19 infection among Health care workers (HCWs) from the health care provider's perspective. METHODS: A deterministic baseline model, without any mask use, based on Eikenberry et al was used to form the foundation for parameter estimation and to estimate transmission rates among HCWs. Information on mask efficacy, including the overall filtering efficiency of a mask and clinical efficiency, in terms of either inward efficiency(ei) or outward efficiency(e0), was obtained from published literature. Hospitalized HCWs were assumed to be in one of the disease states i.e., mild, moderate, severe, or critical. A total of 10,000 HCWs was considered as representative of the size of a tertiary care institution HCW population. The utility values for the mild, moderate and severe model health states were sourced from the primary data collection on quality-of-life of HCWs COVID-19 survivors. The utility scores for mild, moderate, and severe COVID-19 conditions were 0.88, 0.738 and 0.58, respectively. The cost of treatment for mild sickness (6,500 INR per day), moderate sickness (10,000 INR per day), severe (require ICU facility without ventilation, 15,000 INR per day), and critical (require ICU facility with ventilation per day, 18,000 INR) per day as per government and private COVID-19 treatment costs and capping were considered. One way sensitivity analyses were performed to identify the model inputs which had the largest impact on model results. RESULTS: The use of N95 masks compared to using no mask is cost-saving of $1,454,632 (INR 0.106 billion) per 10,000 HCWs in a year. The use of N95 masks compared to using surgical masks is cost-saving of $63,919 (INR 0.005 billion) per 10,000 HCWs in a year. the use of surgical masks compared to using no mask is cost-saving of $1,390,713 (INR 0.102 billion) per 10,000 HCWs in a year. The uncertainty analysis showed that considering fixed transmission rate (1.7), adoption of mask efficiency as 20%, 50% and 80% reduces the cumulative relative mortality to 41%, 79% and 94% respectively. On considering ei = e0 (99%) for N95 and surgical mask with ei = e0 (90%) the cumulative relative mortality was reduced by 97% and the use of N95 masks compared to using surgical masks is cost-saving of $24,361 (INR 0.002 billion) per 10,000 HCWs in a year. DISCUSSION: Both considered interventions were dominant compared to no mask based on the model estimates. N95 masks were also dominant compared to surgical masks.

Cost-Effectiveness of Currently Available Diagnostic Tools for Diagnosis of Pediatric Tuberculosis Under National Tuberculosis Elimination Program.

In India, children do not get diagnosed with tuberculosis (TB) for reasons such as lack of screening modality at the health-care settings, inadequate sputum sample, and low detection rate. This study aims to assess various modalities for diagnosis of pediatric TB and their cost-effectiveness. Cost-effectiveness was found for various diagnostic modalities for TB diagnosis in children of India below 15 years of age. TrueNat MTB was the intervention being compared to GeneXpert MTB and sputum microscopy. Evidence pertinent to effectiveness and cost per test, and health benefits in terms of disability adjusted life years were researched and documented. Modeling a cohort of children through a decision tree and assimilating costs and disability-adjusted life years (DALYs) at each step gave results in the form of cost-effectiveness. Interventions were compared by calculating the cost-effectiveness ratio. The results revealed that TrueNat is more cost effective (Rs. 9450/DALY averted) compared to GeneXpert MTB/RIF (Rs. 9750/DALY averted). The incremental cost effectiveness ratio of TrueNat with respect to GeneXpert was found to be Rs. 5925 per DALY averted. Diagnosis through TrueNat point of care (POC) will avert 962 more DALYs compared to GeneXpert. As is evident from the results, TrueNat does alleviate disability caused by TB in children as more DALYs are averted. At an additional cost of Rs. 5925 to avert one DALY, which is below the gross domestic product (GDP) per capita for India (for 2021, it was $2277), TrueNat can have significant health benefits.

Feasibility, Outcomes, and Safety of Telehepatology Services During the COVID-19 Pandemic.

Coronavirus disease 2019 (COVID-19) has hampered health care delivery globally. We evaluated the feasibility, outcomes, and safety of telehepatology in delivering quality care amid the pandemic. A telemedicine setup using smartphones by hepatologists was organized at our tertiary-care center after pilot testing. Consecutive patients availing telehepatology services were recruited between March and July 2020. An adapted model for assessment of telemedicine was used after validity and reliability testing, to evaluate services 7-21 days after index teleconsultation. Of the 1,419 registrations, 1,281 (90.3%) consultations were completed. From 245 randomly surveyed patients, 210 (85.7%) responded (age [years, interquartile range]: 46 [35-56]; 32.3% females). Seventy percent of patients belonged to the middle or lower socio-economic class, whereas 61% were from rural areas. Modes of teleconsultation were audio (54.3%) or hybrid video call (45.7%). Teleconsultation alone was deemed suitable in 88.6% of patients. Diagnosis and compliance rates were 94% and 82.4%, respectively. Patients' convenience rate, satisfaction rate, improvement rate, success rate, and net promoter scores were 99.0%, 85.2%, 49.5%, 46.2% and 70, respectively. Physical and mental quality of life improved in 67.1% and 82.8% of patients, respectively, following index teleconsultation. Person-hours and money spent by patients were significantly lower with teleconsultation (P < 0.001); however, person-hours spent by hospital per teleconsultation were higher than in physical outpatient services (P < 0.001). Dissatisfied patients were more likely to have lower diagnosis rate, unsuitability for teleconsultation, noncompliance, poorer understanding, and uncomfortable conversation during teleconsultation. Connectivity issues (22.9%) were the most common barrier. Three patients, all of whom were advised emergency care during teleconsultation, succumbed to their illness. Conclusion: Telehepatology is a feasible and reasonably effective tool for rendering health care services using smartphones during the COVID-19 pandemic. Systematic implementation, possible integration into routine health care delivery, and formal cost-effectiveness of telehepatology services need further exploration.

A rapid and cost-effective method based on dispersive liquid-liquid microextraction coupled to injection port silylation-gas chromatography-mass spectrometry for determination of morphine in illicit opium.

A simple, rapid, cost-effective and environment friendly analytical method based on dispersive liquid-liquid microextraction (DLLME) coupled to injection port silylation (IPS)-gas chromatography-mass spectrometry is described for the determination of morphine in illicit opium samples. Raw opium was dispersed in ultrapure water and 5 mL of aqueous sample was subjected to DLLME by rapidly injecting a mixture of chloroform and acetone (extraction and disperser solvent, respectively) followed by ultrasonication for 1 min and subsequent centrifugation for 3 min at 5000 rpm. The sedimented phase thus obtained was reconstituted in acetonitrile and 1 µL along with 1 µL of N,O-Bis(trimethylsilyl)acetamide (BSA) was injected manually into GC-MS injection port at a temperature of 250°C. The derivatization reaction was completed instantaneously inside the heated GC-MS injection port without any side product. Various parameters associated with IPS and DLLME have been thoroughly optimized. Under the optimized conditions, the method has been found linear in the range of 5-50 µg/mL with a correlation coefficient (R 2) of 0.997. The limit of detection (LOD) and limit of quantification (LOQ) for morphine-diTMS were found to be 1.6 and 4.8 µg/mL. The method has been successfully applied for the quantitative analysis of morphine in illicit opium samples. In conclusion, the proposed method has completely eliminated the time consuming and laborious steps of LLE and in-vial silylation and can be routinely used for analysis of opium and other polar analytes in forensic science laboratories.

Congenital rubella syndrome at tertiary care hospital in North India: Results from a retrospective assessment.

A retrospective survey of medical records of children discharged with a diagnosis of congenital rubella syndrome (CRS) from our hospital between January 2005 and December 2015 was performed. There were 28 clinically diagnosed cases of CRS during this period. A total of 17 children (61%) out of 28; had laboratory evidence of immunoglobulin M (IgM) rubella positivity in their serum sample. There were 24 male and 4 female infants (M:F = 6:1; mean age, 2.8 ± 3.5 months). None of the mothers received rubella vaccination in the past. All the infants had low birth weight; 21 had microcephaly. Structural heart defects (21 of 28) was the most prominent manifestation in these infants; of these, patent ductus arteriosus (PDA; 15/28) was the most common one. Other manifestations included cataract (18 of 28), hearing impairment (8 of 28), purpuric rash (6 of 28), developmental delay (8 of 28) and hepatosplenomegaly (26 of 28). Of the 18 children with cataract, 12 had bilateral and 6 had unilateral cataract. There is an urgent need to start effective CRS surveillance and preventive measures including appropriate vaccination against rubella.

A randomized controlled trial of hospital versus home based therapy with oral amoxicillin for severe pneumonia in children aged 3 - 59 months: The IndiaCLEN Severe Pneumonia Oral Therapy (ISPOT) Study.

BACKGROUND: Pneumonia is the leading cause of child mortality under five years of age worldwide. For pneumonia with chest indrawing in children aged 3-59 months, injectable penicillin and hospitalization was the recommended treatment. This increased the health care cost and exposure to nosocomial infections. We compared the clinical and cost outcomes of a seven day treatment with oral amoxicillin with the first 48 h of treatment given in the hospital (hospital group) or at home (home group). METHODS: We conducted an open-label, multi-center, two-arm randomized clinical trial at six tertiary hospitals in India. Children aged 3 to 59 months with chest indrawing pneumonia were randomized to home or hospital group. Clinical outcomes, treatment adherence, and patient safety were monitored through home visits on day 3, 5, 8, and 14 with an additional visit for the home group at 24 h. Clinical outcomes included treatment failure rates up to 7 days (primary outcome) and between 8-14 days (secondary outcome) using the intention to treat and per protocol analyses. Cost outcomes included direct medical, direct non-medical and indirect costs for a random 17% subsample using the micro-costing technique. RESULTS: 1118 children were enrolled and randomized to home (n = 554) or hospital group (n = 564). Both groups had similar baseline characteristics. Overall treatment failure rate was 11.5% (per protocol analysis). The hospital group was significantly more likely to fail treatment than the home group in the intention to treat analysis. Predictors with increased risk of treatment failure at any time were age 3-11 months, receiving antibiotics within 48 h prior to enrolment and use of high polluting fuel. Death rates at 7 or 14 days did not differ significantly. (Difference -0.0%; 95% CI -0.5 to 0.5). The median total treatment cost was Rs. 399 for the home group versus Rs. 602 for the hospital group (p < 0.001), for the same effect of 5% failure rate at the end of 7 days of treatment in the random subsample. CONCLUSIONS: Home based oral amoxicillin treatment was equivalent to hospital treatment for first 48 h in selected children of chest indrawing pneumonia and was cheaper. Consistent with the recent WHO simplified guidelines, management with home based oral amoxicillin for select children with only fast breathing and chest-indrawing can be a cost effective intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT01386840, registered 25th June 2011 and the Indian Council of Medical Research REFCTRI/2010/000629.

Four years of experience of telemedicine for paediatric care in three Punjab hospitals, North India: achievements and lessons.

Children in India constitute a very high risk group from mortality and morbidity due to lack of specialised healthcare. Remote care of paediatric patients by offsite specialists using telemedicine technology is a highly potential solution for coping up with the shortage of specialists in Indian subcontinent. We at a tertiary care teaching hospital in North India assessed the application of telemedicine services for diagnosis and management of paediatric illnesses, through prospective analyses of electronic databases over 4 years. The age groups covered were from newborn up to children of 15 years of age. The outcomes assessed were: feasibility, diagnostic possibilities, management, outcomes, referral and mean costs per patient. The results were as follows: major consultations involved children <5 years age, with neonates contributing to 5.5% of the total consultations. The major system-related problems were: gastrointestinal, respiratory, neurological, infectious and haematological. Referral was advised in 14.3% of cases. Ten percent of children were critically ill and could not have been in a position to be transported safely. Videoconferencing was done in 21.4% patients. There was a paucity of feedback and follow up of these consultations (12% of the total). The total savings for all the consultations per child was ≈1000 Indian rupees (approximately US$22) leaving behind the telemedicine consultation charges. To conclude, telepaediatrics in India is still in its fetal stage. The hurdles and medico-legal issues need to be addressed before the telepaediatrics service is widely accepted in India.

Whooping cough: the current scene.

Pertussis, a highly contagious disease caused by Bordetella pertussis, is making a comeback globally despite good immunization coverage. The developed countries have also shown a shift in the epidemiology of the disease to the adolescent and the adult age group, leading to a revision of their vaccination policies. The disease epidemiology in the South East Asian region seems poised for a similar change. Outbreaks have been reported among children and adults in countries such as Afghanistan, Israel, and Taipei. The anticipation and early recognition of this change in the epidemiology is important because the affected adolescents and adults act as reservoirs of the disease to the vulnerable population of infants, for whom the disease can be life threatening. The clinical presentation can be atypical in the adolescent age group, and the disease is often misdiagnosed. With the availability of polymerase chain reaction and serology, the disease can be diagnosed even later in the course of the disease when culture results are often negative. The whole-cell pertussis vaccine dramatically reduced the incidence of the disease but fell into disrepute due to the rare serious neurologic side effects that led to the introduction of the acellular pertussis vaccine, which led to fewer adverse reactions and also proved to be safe and effective in the adolescent age group when used as a booster. However, the cost of the acellular vaccine is may be prohibitive for widespread use in the developing nations of the South East Asian region.

The burden of asthma in children: an Asian perspective.

A worldwide increase in the prevalence of asthma has been reported in recent years. With an increase in prevalence comes an increased burden of disease in terms of morbidity, mortality and compromised quality of life. The economic burden in terms of utilisation of healthcare resources and limitation of the earning capacity of the individuals and families is an added problem. Various indicators such as disability-adjusted life years and healthy life years have been used to define the economic burden. The data from Asian countries regarding these parameters is scarce, underlining the need for systematic studies in these countries, especially those that are resource poor. The purpose of this review is to highlight the varying prevalence of asthma in Asia and to assess the likely economic burden for the future.