Group-based trajectory models of integrated vaccine delivery and equity in low- and middle-income countries.

BACKGROUND: Integrated vaccine delivery - the linkage of routine vaccination with provision of other essential health services - is a hallmark of robust primary care systems that has been linked to equitable improvements in population health outcomes. METHODS: We gathered longitudinal data relating to routine immunization coverage and vaccination equity in 78 low- and middle-income countries that have ever received support from Gavi, the Vaccine Alliance, using multiple imputation to handle missing values. We then estimated several group-based trajectory models to describe the relationship between integrated vaccine delivery and vaccination equity in these countries. Finally, we used multinomial logistic regression to identify predictors of group membership. RESULTS: We identified five distinct trajectories of geographic vaccination equity across both the imputed and non-imputed datasets, along with two and four trajectories of socioeconomic vaccination equity in the imputed and non-imputed datasets, respectively. Integration was associated with reductions in the slope index of inequality of measles vaccination in the countries analyzed. Integration was also associated with an increase in the percentage of districts reporting high measles vaccination coverage. CONCLUSIONS: Integrated vaccine delivery is most strongly associated with improvements in vaccination equity in settings with high baseline levels of inequity. Continued scholarship is needed to further characterize the relationship between integration and health equity, as well as to improve measurement of vaccination coverage and integration.

Cost-Effectiveness of the COVID-19 Test, Trace and Isolate Program in Colombia.

BACKGROUND: During the COVID-19 pandemic, Test-Trace-Isolate (TTI) programs have been recommended as a risk mitigation strategy. However, many governments have hesitated to implement them due to their costs. This study aims to estimate the cost-effectiveness of implementing a national TTI program to reduce the number of severe and fatal cases of COVID-19 in Colombia. METHODS: We developed a Markov simulation model of COVID-19 infection combined with a Susceptible-Infected-Recovered structure. We estimated the incremental cost-effectiveness of a comprehensive TTI strategy compared to no intervention over a one-year horizon, from both the health system and the societal perspective. Hospitalization and mortality rates were retrieved from Colombian surveillance data. We included program costs of TTI intervention, health services utilization, PCR diagnosis test, productivity loss, and government social program costs. We used the number of deaths and quality-adjusted life years (QALYs) as health outcomes. Sensitivity analyses were performed. FINDINGS: Compared with no intervention, the TTI strategy reduces COVID-19 mortality by 67%. In addition, the program saves an average of $1,045 and $850 per case when observed from the social and the health system perspective, respectively. These savings are equivalent to two times the current health expenditures in Colombia per year. INTERPRETATION: The TTI program is a highly cost-effective public health intervention to reduce the burden of COVID-19 in Colombia. TTI programs depend on their successful and speedy implementation. FUNDING: This study was supported by the Colombian Ministry of Health through award number PUJ-04519-20 received by EPQ AVO and SDS declined to receive any funding support for this study. The contents are the responsibility of all the individual authors.

Examining the cost-effectiveness of personal protective equipment for formal healthcare workers in Kenya during the COVID-19 pandemic.

BACKGROUND: Healthcare workers are at a higher risk of COVID-19 infection during care encounters compared to the general population. Personal Protective Equipment (PPE) have been shown to protect COVID-19 among healthcare workers, however, Kenya has faced PPE shortages that can adequately protect all healthcare workers. We, therefore, examined the health and economic consequences of investing in PPE for healthcare workers in Kenya. METHODS: We conducted a cost-effectiveness and return on investment (ROI) analysis using a decision-analytic model following the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines. We examined two outcomes: 1) the incremental cost per healthcare worker death averted, and 2) the incremental cost per healthcare worker COVID-19 case averted. We performed a multivariate sensitivity analysis using 10,000 Monte Carlo simulations. RESULTS: Kenya would need to invest $3.12 million (95% CI: 2.65-3.59) to adequately protect healthcare workers against COVID-19. This investment would avert 416 (IQR: 330-517) and 30,041 (IQR: 7243 - 102,480) healthcare worker deaths and COVID-19 cases respectively. Additionally, such an investment would result in a healthcare system ROI of $170.64 million (IQR: 138-209) - equivalent to an 11.04 times return. CONCLUSION: Despite other nationwide COVID-19 prevention measures such as social distancing, over 70% of healthcare workers will still be infected if the availability of PPE remains scarce. As part of the COVID-19 response strategy, the government should consider adequate investment in PPE for all healthcare workers in the country as it provides a large return on investment and it is value for money.

A cost study for mobile phone health surveys using interactive voice response for assessing risk factors of noncommunicable diseases.

BACKGROUND: This is the first study to examine the costs of conducting a mobile phone survey (MPS) through interactive voice response (IVR) to collect information on risk factors for noncommunicable diseases (NCD) in three low- and middle-income countries (LMIC); Bangladesh, Colombia, and Uganda. METHODS: This is a micro-costing study conducted from the perspective of the payer/funder with a 1-year horizon. The study evaluates the fixed costs and variable costs of implementing one nationally representative MPS for NCD risk factors of the adult population. In this costing study, we estimated the sample size of calls required to achieve a population-representative survey and associated incentives. Cost inputs were obtained from direct economic costs incurred by a central study team, from country-specific collaborators, and from platform developers who participated in the deployment of these MPS during 2017. Costs were reported in US dollars (USD). A sensitivity analysis was conducted assessing different scenarios of pricing and incentive strategies. Also, costs were calculated for a survey deployed targeting only adults younger than 45 years. RESULTS: We estimated the fixed costs ranging between $47,000 USD and $74,000 USD. Variable costs were found to be between $32,000 USD and $129,000 USD per nationally representative survey. The main cost driver was the number of calls required to meet the sample size, and its variability largely depends on the extent of mobile phone coverage and access in the country. Therefore, a larger number of calls were estimated to survey specific harder-to-reach sub-populations. CONCLUSION: Mobile phone surveys have the potential to be a relatively less expensive and timely method of collecting survey information than face-to-face surveys, allowing decision-makers to deploy survey-based monitoring or evaluation programs more frequently than it would be possible having only face-to-face contact. The main driver of variable costs is survey time, and most of the variability across countries is attributable to the sampling differences associated to reaching out to population subgroups with low mobile phone ownership or access.

Cost-effectiveness and return on investment of protecting health workers in low- and middle-income countries during the COVID-19 pandemic.

BACKGROUND: In this paper, we predict the health and economic consequences of immediate investment in personal protective equipment (PPE) for health care workers (HCWs) in low- and middle-income countries (LMICs). METHODS: To account for health consequences, we estimated mortality for HCWs and present a cost-effectiveness and return on investment (ROI) analysis using a decision-analytic model with Bayesian multivariate sensitivity analysis and Monte Carlo simulation. Data sources included inputs from the World Health Organization Essential Supplies Forecasting Tool and the Imperial College of London epidemiologic model. RESULTS: An investment of $9.6 billion USD would adequately protect HCWs in all LMICs. This intervention would save 2,299,543 lives across LMICs, costing $59 USD per HCW case averted and $4,309 USD per HCW life saved. The societal ROI would be $755.3 billion USD, the equivalent of a 7,932% return. Regional and national estimates are also presented. DISCUSSION: In scenarios where PPE remains scarce, 70-100% of HCWs will get infected, irrespective of nationwide social distancing policies. Maintaining HCW infection rates below 10% and mortality below 1% requires inclusion of a PPE scale-up strategy as part of the pandemic response. In conclusion, wide-scale procurement and distribution of PPE for LMICs is an essential strategy to prevent widespread HCW morbidity and mortality. It is cost-effective and yields a large downstream return on investment.

Distributional health and financial benefits of increased tobacco taxes in Colombia: results from a modelling study.

BACKGROUND: In Colombia, smoking is the second leading modifiable risk factor for premature mortality. In December 2016, Colombia passed a major tax increase on tobacco products in an effort to decrease smoking and improve population health. While tobacco taxes are known to be highly effective in reducing the prevalence of smoking, they are often criticised as being regressive in consumption. This analysis attempts to assess the distributional impact (across socioeconomic groups) of the new tax on selected health and financial outcomes. METHODS: This study builds on extended cost-effectiveness analysis methods to study the new tobacco tax in Colombia, and estimates, over a time period of 20 years and across income quintiles of the current urban population (80% of the country population), the years of life gained with smoking cessation and the increased tax revenues, all associated with a 70% relative price increase of the pack of cigarettes. Where possible, we use parameters that vary by income quintile, including price elasticity of demand for cigarettes (average of -0.44 estimated from household survey data). FINDINGS: Over 20 years, the tax increase would lead to an estimated 191 000 years of life gained among Colombia's current urban population, with the largest gains among the bottom two income quintiles. The additional annual tax revenues raised would amount to about 2%-4% of Colombia's annual government health expenditure, with the poorest quintiles bearing the smallest tax burden increase. CONCLUSIONS: The tobacco tax increase passed by Colombia has substantial implications for the country's population health and financial well-being, with large benefits likely to accrue to the two poorest quintiles of the population.

A tax on sugar sweetened beverages in Colombia: Estimating the impact on overweight and obesity prevalence across socio economic levels.

Colombia has a high prevalence of overweight (56%) and obesity (19%) among adults and is experiencing a growing trend in the prevalence of associated chronic conditions. Evidence suggests that sugar sweetened beverages (SSB) are associated to overweight/obesity, and that taxes on these beverages could reduce their associated health consequences. This paper assesses the potential effect of different levels of a SSB tax in Colombia on overweight and obesity prevalence. Using peer-reviewed local data on own-price elasticity of SSB, we applied a comparative risk assessment strategy to simulate the effect of the SSB tax on a nationally representative nutritional survey with 7140 adults in 2010 (ENSIN, 2010). Our results varied depending on the tax scenario, pass-through assumption and household socio economic strata (SES). We found that among individuals belonging to lower SES households, the SSB tax would reduce overweight and obesity between 1.5-4.9 and 1.1-2.4 percentage points (p < 0.05), respectively. Among individuals belonging to higher SES households, we found no statistically significant effects on obesity, and a reduction on overweight prevalence between 2.9 and 3.9 percentage points (p < 0.05). In the most conservative scenario (40% pass-through), a tax rate of at least 75 cents of Colombian peso (0.75 COP) per milliliter (24% of the average price) is needed to have statistically significant effects on both overweight and obesity prevalence among lower SES households. The results of this study suggest that a SSB tax could reduce the overweight and obesity prevalence in Colombia, especially among lower SES households. This study shows that SSB taxes have a particularly beneficial effect in the most vulnerable population. Additional social and individual benefits, or individual costs arising from the tax are not assessed in this research, implying that even larger health gains could be observed.

Impact of a multiplex PCR point-of-care test for influenza A/B and respiratory syncytial virus on an acute pediatric hospital ward.

Patients with respiratory infections are often managed presumptively until confirmation of infection status. We assessed the impact of introducing the Enigma® MiniLab™ FluAB-RSV point-of-care test (POCT) on patients admitted with a suspected respiratory virus driven illness in an acute pediatric ward. This utilized a before and after design (respiratory viral seasons 2013/14 versus 2014/15). Following POCT implementation, oseltamivir prescribing increased in patients with influenza (OR = 12.7, P = 0.05, 95% CI [1.0, 153.8]). A reduction in the average reimbursement charges without a change in the length of stay was observed. Modeling suggested that laboratory test cost savings could be achieved if the POCT cost £30 and was used for screening, followed by the respiratory viral panel for RSV and influenza negative patients. A rapid POCT for influenza A/B and RSV infections in pediatric inpatients may improve oseltamivir prescribing, strengthen antimicrobial stewardship, reduce reimbursement charges and decrease laboratory costs.

Effective interventions for unintentional injuries: a systematic review and mortality impact assessment among the poorest billion.

BACKGROUND: Between 1990 and 2015, the global injury mortality declined, but in countries where the poorest billion live, injuries are becoming an increasingly prevalent cause of death. The vulnerability of this population requires immediate attention from policy makers to implement effective interventions that lessen the burden of injuries in these countries. Our aim was two-fold; first, to review all the evidence on effective interventions for the five main types of unintentional injury; and second, to estimate the potential number of lives saved by effective injury interventions among the poorest billion. METHODS: For our systematic review we used references in the Disability Control Priorities third edition, and searched PubMed and the Cochrane database for papers published until Sept 10, 2016, using a comprehensive search strategy to find interventions for the five major causes of unintentional injuries: road traffic crashes, falls, drowning, burns, and poisoning. Studies were included if they presented evidence with significant effects sizes for any outcome; no inclusions or exclusions made on the basis of where the study was carried out (ie, low-income, middle-income, or high-income country). Then we used data from the Global Burden of Disease 2015 study and a Monte Carlo simulation technique to estimate the potential annual attributable number of lives saved among the poorest billion by these evidence-based injury interventions. We estimated results for 84 countries where the poorest billion live. FINDINGS: From the 513 papers identified, 47 were eligible for inclusion. We identified 11 interventions that had an effect on injury mortality. For road traffic deaths, the most successful interventions in preventing deaths are speed enforcement (>80 000 lives saved per year) and drink-driving enforcement (>60 000 lives saved per year). Interventions potentially most effective in preventing deaths from drowning are formal swimming lessons for children younger than 14 years (>25 000 lives saved per year) and the use of crèches to supervise younger children (younger than 5 years; >10 000 lives saved per year). We did not find sufficient evidence on interventions for other causes of unintentional injuries (poisoning, burns, and falls) to run similar simulations. INTERPRETATION: Based on the little available evidence, key interventions have been identified to prevent lives lost from unintentional injuries among the poorest billion. This Article provides guidance to national authorities on evidence-based priority interventions that can reduce the burden of injuries among the most vulnerable members of the population. We also identify an important gap in knowledge on the effectiveness and the mortality impacts of injury interventions. FUNDING: Partly supported by the Fogarty International Center of the US National Institutes of Health (Chronic Consequences of Trauma, Injuries, Disability Across the Lifespan: Uganda; #D43TW009284).

Presenteeism, Absenteeism, and Lost Work Productivity among Depressive Patients from Five Cities of Colombia.

OBJECTIVES: To estimate productivity losses due to absenteeism and presenteeism and their determinants in patients with depression from five Colombian cities. METHODS: We used data from a multicenter, mixed-methods study of adult patients diagnosed with major depressive disorder or double depression (major depressive disorder plus dysthymia) during 2010. The World Health Organization's Health and Work Performance Questionnaire was used to assess absenteeism and presenteeism. We explored the determinants of productivity losses using a two-part model. We also used a costing model to calculate the corresponding monetary losses. RESULTS: We analyzed data from 107 patients employed in the last 4 weeks. Absenteeism was reported by 70% of patients; presenteeism was reported by all but one. Half of the patients reported a level of performance at work at least 50% below usual. Average number of hours per month lost to absenteeism and presenteeism was 43 and 51, respectively. The probability of any absenteeism was 17 percentage points lower in patients rating their mental health favorably compared with those rating it poorly (standard error [SE] 0.09; P < 0.10) and 19 percentage points higher in patients with at least one comorbidity compared with patients with none (SE 0.10; P < 0.10). All other covariates showed no significant associations on hours lost to absenteeism. Patients with favorable mental health self-ratings had 16.4 fewer hours per month of presenteeism compared with those with poor self-ratings (SE 4.52; P < 0.01). The 2015 monetary value of productivity losses amounted to US $840 million. CONCLUSIONS: This study in a middle-income country confirms the high economic burden of depression. Health policies and workplace interventions ensuring adequate diagnosis and treatment of depression are recommended.

The impact of practice guidelines on opioid utilization for injured workers.

BACKGROUND: Opioid use is rising in the US and may cause special problems in workers compensation cases, including addiction and preventing a return to work after an injury. OBJECTIVE: This study evaluates a physician-level intervention to curb opioid usage. An insurer identified patients with out-of-guideline opioid utilization and called the prescribing physician to discuss the patient's treatment protocol. RESEARCH DESIGN: This study uses a differences-in-differences study design with a propensity-score-matched control group. Medical and pharmaceutical claims data from 2005 to 2011 were used for analyses. RESULTS: Following the intervention, the use of opioids increased for the intervention group and there is little impact on medical spending. CONCLUSIONS: Counseling physicians about patients with high opioid utilization may focus more attention on their care, but did not impact short-term outcomes. More robust interventions may be needed to manage opioid use. PERSPECTIVE: While the increasing use of opioids is of growing concern around the world, curbing the utilization of these powerfully addictive narcotics has proved elusive. This study examines a prescribing guidelines intervention designed to reduce the prescription of opioids following an injury. The study finds that there was little change in the opioid utilization after the intervention, suggesting interventions along other parts of the prescribing pathway may be needed.

Comparison of Health Examination Survey Methods in Brazil, Chile, Colombia, Mexico, England, Scotland, and the United States.

Comparability of population surveys across countries is key to appraising trends in population health. Achieving this requires deep understanding of the methods used in these surveys to examine the extent to which the measurements are comparable. In this study, we obtained detailed protocols of 8 nationally representative surveys from 2007-2013 from Brazil, Chile, Colombia, Mexico, the United Kingdom (England and Scotland), and the United States-countries that that differ in economic and inequity indicators. Data were collected on sampling frame, sample selection procedures, recruitment, data collection methods, content of interview and examination modules, and measurement protocols. We also assessed their adherence to the World Health Organization's "STEPwise Approach to Surveillance" framework for population health surveys. The surveys, which included half a million participants, were highly comparable on sampling methodology, survey questions, and anthropometric measurements. Heterogeneity was found for physical activity questionnaires and biological samples collection. The common age range included by the surveys was adults aged 18-64 years. The methods used in these surveys were similar enough to enable comparative analyses of the data across the 7 countries. This comparability is crucial in assessing and comparing national and subgroup population health, and to assisting the transfer of research and policy knowledge across countries.

BRICS: opportunities to improve road safety.

Brazil, the Russian Federation, India, China and South Africa--the countries known as BRICS--are currently undergoing a deep epidemiological transition that is mainly driven by rapid economic growth and technological change. The changes being observed in the distribution of the burden of diseases and injuries--such as recent increases in the incidence of road traffic injuries--are matters of concern. BRICS may need stronger institutional capacity to address such changes in a timely way. In this paper, we present data on road traffic injuries in BRICS and illustrate the enormous challenge that these countries currently face in reducing the incidence of such injuries. There is an urgent need to improve road safety indicators in every country constituting BRICS. It is imperative for BRICS to invest in system-wide road safety interventions and reduce the mortality and morbidity from road traffic injuries.

Le Brésil, la Fédération de Russie, l'Inde, la Chine et l'Afrique du Sud ­ les pays connus sous le nom de BRICS ­ connaissent actuellement une transition épidémiologique profonde qui s'explique principalement par la rapidité de la croissance économique et de l'évolution technologique. Les changements qui sont observés dans la distribution de la charge des maladies et des blessures, comme les hausses récentes de l'incidence des accidents de la route, suscitent des inquiétudes. Le groupe BRICS peut avoir besoin de capacités institutionnelles renforcées pour répondre rapidement à ces changements. Dans cet article, nous présentons les données sur les accidents de la route dans le groupe BRICS et nous illustrons l'énorme défi que doivent actuellement relever ces pays dans la diminution de l'incidence de ces accidents. Il est urgent d'améliorer les indicateurs de la sécurité routière dans chaque pays constituant le groupe BRICS. Il est impératif que le groupe BRICS investisse dans des interventions de sécurité routière dans l'ensemble du système et qu'il réduise la mortalité et la morbidité dues aux accidents de la route.

Brasil, la Federación de Rusia, India, China y Sudáfrica, los países conocidos como BRICS, se encuentran en la actualidad en una transición epidemiológica profunda impulsada principalmente por el rápido crecimiento económico y el cambio tecnológico. Los cambios que se observan en la distribución de la carga de enfermedades y lesiones, como los aumentos recientes de la incidencia de los accidentes de tráfico, son motivo de preocupación. Es posible que los BRICS necesiten una capacidad institucional más fuerte para hacer frente a esos cambios de manera oportuna. En el presente artículo, presentamos datos sobre lesiones en accidentes de tráfico de los BRICS e ilustramos el enorme desafío al que dichos países se enfrentan actualmente para reducir la incidencia de las mismas. Hay una necesidad urgente de mejorar los indicadores de seguridad vial en todos los países BRICS. Es imperativo que estos países inviertan en intervenciones de seguridad vial en todo el sistema y reduzcan la mortalidad y morbilidad por accidentes de tráfico.

The use of cost-benefit analysis in road assessments: a methodological inquiry.

BACKGROUND: Cost-benefit analysis is a useful tool for priority setting in road safety. The value of statistical life (VOSL) is a metric used to estimate the benefits of road interventions in cost-benefit analyses. The International Road Assessment Program (iRAP), for example, created a rule-of-thumb to calculate VOSL benefits of road infrastructure when performing cost-benefit assessments in countries where data on VOSL are sparse. AIM: To evaluate the rapid assessment metric developed by iRAP and provide suggestions for improvement in these methods. METHODS: We replicated iRAP calculations in order to make a critical assessment of the sources, results and conclusions. CONCLUSIONS: We found the iRAP metric a good example for highlighting some relevant aspects that should be considered in any VOSL estimation in order to enhance its use as a guiding principle for assessing road interventions. Specifically, we recommend the explicit disclosure of the assumptions, the use of sensitivity analysis and the avoidance of omitted variables bias.