Trade-offs in the externalities of pig production are not inevitable.

Farming externalities are believed to co-vary negatively, yet trade-offs have rarely been quantified systematically. Here we present data from UK and Brazilian pig production systems representative of most commercial systems across the world ranging from 'intensive' indoor systems through to extensive free range, Organic and woodland systems to explore co-variation among four major externality costs. We found that no specific farming type was consistently associated with good performance across all domains. Generally, systems with low land use have low greenhouse gas emissions but high antimicrobial use and poor animal welfare, and vice versa. Some individual systems performed well in all domains but were not exclusive to any particular type of farming system. Our findings suggest that trade-offs may be avoidable if mitigation focuses on lowering impacts within system types rather than simply changing types of farming.

The Yield, Safety, and Cost-effectiveness of Decreasing Repeat Blood Cultures Beyond 48 Hours in a Pediatric Hematology-Oncology Unit.

Clear recommendations are needed on when repeat blood cultures (BCxs) in hospitalized children with cancer should be obtained. We reviewed all BCx obtained on the Hematology-Oncology Unit at Riley Hospital for Children, regardless of reason for patient admission or neutropenia status, between January 2015 and February 2021. Patients with positive BCx within 48 hours of initial cultures, history of stem cell transplant, or admitted to the intensive care unit were excluded. Medical records of patients with new positive BCx drawn >48 hours after initial BCx were reviewed. Seven (1.2%) hospitalization episodes grew new pathogens, or commensals treated as pathogens, on cultures beyond 48 hours. All patients with new, true pathogens were hemodynamically unstable or had recurrent fever when the new positive BCx was obtained. Twenty-three (4.0%) hospitalization episodes had contaminant cultures beyond 48 hours, with 74 (5.4%) of 1362 BCx collected beyond 48 hours being contaminated, resulting in an additional cost of $210,519 from increased length of stay. In conclusion, repeat BCx beyond 48 hours in pediatric hematology-oncology patients with negative initial cultures are low yield and costly. Repeat BCx can be safely and cost-effectively ceased after 48 hours of negative cultures in hemodynamically and clinically stable patients.

Productivity loss and cost of bovine tuberculosis for the dairy livestock sector in Ethiopia.

Bovine tuberculosis (BTB) is endemic in Ethiopia. Although upgraded dairy cattle account for only 1% of the total cattle population, they are the backbone of the marketed milk production in the country. Supported by research data outputs from three years, we report in this paper an estimate of the productivity loss and cost of BTB to the Ethiopian dairy sector in two dairy settings, the urban production system in Central Ethiopia (model 1) and the national upgraded dairy production (model 2). Primary data sources were used (e.g. market survey; three-year longitudinal productivity survey; abattoir survey) as well as secondary data sources. A matrix population model, composed of a population vector representing the herd composition that is repeatedly multiplied with a projection matrix, was developed to simulate the livestock dairy population. The initial herd structure was simulated over 30 years to obtain an equilibrium herd-structure representing an Eigenvector of the projection matrix. We performed an incremental cost of disease analysis by comparing livestock production with and without BTB during a period of 10 years. We assumed a BTB prevalence of 40%. In year ten, the Net present value (NPV) of livestock production in terms of milk, meat and hides was estimated at 154.5 million USD for model 1 and 1.7 billion USD for model 2. Loss of NPV over 10 years was estimated at 12 million USD for model 1 and 131.7 million USD for model 2, representing roughly 7.3% loss in NPV or 219 USD per animal. This is a benchmark against which a national TB control program could be developed in the future to calculate its benefit/cost ratio.

Impact of a structured older persons health assessment on herpes zoster vaccine uptake in Australian primary care.

Vaccine uptake in adult immunisation programs is often suboptimal. We aimed to assess the impact of the structured older persons health assessment (health assessment) on herpes zoster (zoster) vaccine uptake in Australia. We used national general practice electronic medical records (MedicineInsight) of encounters with patients aged 75-79 years because these patients were age-eligible for both free zoster vaccines and health assessments in the two years following the addition of zoster vaccine to the national immunisation program (Nov 2016-Dec 2018). Due to repeated encounters, we used generalized estimating equations with each patient treated as a clustering variable to analyse the comparison of rates of zoster vaccine administration during encounters where a health assessment was provided versus encounters where the health assessment was not provided. In analyses there were 31,876 patients with a total of 266,204 eligible general practice encounters. Of the 5018 encounters where a health assessment was provided, 592 zoster vaccinations also occurred on the same day (118.0/1000 encounters); for the 261,186 encounters where no health assessment was provided, 9226 zoster vaccinations occurred (35.3/1000 encounters). Zoster vaccine was more likely to be administered during a general practice encounter with a health assessment compared to encounters without one (adjusted odds ratio 2.99; 95% CI: 2.76-3.23). In conclusion, the structured older persons health assessment, which acts as both an incentive and a reminder for healthcare providers to recommend vaccinations in adults improves uptake of zoster vaccine in eligible adults. Such interventions may have a role in improving vaccine uptake among older adults.

Spoligotype analysis of Mycobacterium bovis isolates from cattle and assessment of zoonotic TB transmission among individuals working in bovine TB-infected dairy farms in Ethiopia.

Bovine tuberculosis (bTB) is a disease with impact on dairy productivity, as well as having the potential for zoonotic transmission. Understanding the genetic diversity of the disease agent Mycobacterium bovis is important for identifying its routes of transmission. Here we investigated the level of genetic diversity of M. bovis isolates and assessed the zoonotic potential in risk groups of people working in bTB-infected dairy farms in central Ethiopia. M. bovis was isolated and spoligotyped from tissue lesions collected from slaughtered cattle as well as from raw milk collected from bTB positive cows in dairy farms from six urban areas of central Ethiopia. From consented dairy farm workers, knowledge and practices related to zoonotic TB transmission, together with demographic and clinical information, was collected through interviews. Sputum or Fine Needle Aspirate (FNA) samples were collected from suspected TB cases. Spoligotyping of 55 M. bovis isolates that originated either from cattle tissues with tuberculous lesion or from raw milk revealed seven spoligotype patterns where SB1176 was the most prevalent type (47.3%). Most isolates (89.1%) were of the M. bovis African 2 clonal complex. All sputum and FNA samples from 41 dairy farm workers with symptoms of TB were culture negative for any mycobacteria. Among the 41 TB suspected farm workers, 61% did not know about bTB in cattle and its zoonotic potential, and over two-third of these workers practiced raw milk consumption. Our spoligotype analysis suggests a wider transmission of a single spoligotype in the study area. The results reported here may be useful in guiding future work to identify the source and direction of bTB transmission and hence design of a control strategy. Isolation of M. bovis from milk, knowledge gap on zoonotic TB and practice of consumption of raw milk in the study population showed potential risk for zoonotic transmission.

Global production capacity of seasonal and pandemic influenza vaccines in 2019.

Vaccines will be an important element in mitigating the impact of an influenza pandemic. While research towards developing universal influenza vaccines is ongoing, the current strategy for vaccine supply in a pandemic relies on seasonal influenza vaccine production to be switched over to pandemic vaccines. Understanding how much vaccine could be produced, in which regions of the world and in what timeframe is critical to informing influenza pandemic preparedness. Through the Global Action Plan for Influenza Vaccines, 2006-2016, WHO promoted an increase in vaccine production capacity and monitors the landscape through periodically surveying influenza vaccine manufacturers. This study compares global capacity for production of influenza vaccines in 2019 with estimates from previous surveys; provides an overview of countries with established production facilities; presents vaccine production by type and manufacturing process; and discusses limitations to these estimates. Results of the current survey show that estimated annual seasonal influenza vaccine production capacity changed little since 2015 increasing from 1.47 billion to 1.48 billion doses with potential maximum annual influenza pandemic vaccine production capacity increasing from 6.37 billion to 8.31 billion doses. However, this figure should be interpreted with caution as it presents a best-case scenario with several assumptions which may impact supply. Further, pandemic vaccines would not be immediately available and could take four to six months for first supplies with several more months needed to reach maximum capacity. A moderate-case scenario is also presented of 4.15 billion doses of pandemic vaccine in 12 months. It is important to note that two doses of pandemic vaccine are likely to be required to elicit an adequate immune response. Continued efforts are needed to ensure the sustainability of this production and to conduct research for vaccines that are faster to produce and more broadly protective taking into account lessons learned from COVID-19 vaccine development.

Burden of Congenital Rubella Syndrome (CRS) in Bangladesh: Systematic Review of Existing Literature and Transmission Modelling of Seroprevalence Studies.

BACKGROUND AND OBJECTIVES: Congenital Rubella Syndrome (CRS) is the leading cause of vaccine-preventable congenital anomalies. Comprehensive country-level data on the burden of CRS in low and middle-income countries, such as Bangladesh, are scarce. This information is essential for assessing the impact of rubella vaccination programs. We aim to systematically review the literature on the epidemiology of CRS and estimate the burden of CRS in Bangladesh. METHODS: We conducted a systematic review of existing literature and transmission modelling of seroprevalence studies to estimate the pre-vaccine period burden of CRS in Bangladesh. OVID Medline (1948 - 23 November 2016) and OVID EMBASE (1974 - 23 November 2016) were searched using a combination of the database-specific controlled vocabulary and free text terms. We used an age-stratified deterministic model to estimate the pre-vaccination burden of CRS in Bangladesh. FINDINGS: Ten articles were identified, published between 2000 and 2014, including seven crosssectional studies, two case series and one analytical case-control study. Rubella seropositivity ranged from 47.0% to 86.0% among all age population. Rubella sero-positivity increased with age. Rubella seropositivity among women of childbearing age was 81.0% overall. The estimated incidence of CRS was 0·99 per 1,000 live births, which corresponds to approximately 3,292 CRS cases annually in Bangladesh. CONCLUSION: The estimated burden of CRS in Bangladesh during the pre-vaccination period was high. This will provide important baseline information to assess the impact and cost-effectiveness of routine rubella immunisation, introduced in 2012 in Bangladesh.

Potential Role of Cost and Quality of Life in Treatment Decisions for Arthritis-Related Knee Pain in African American and Latina Women.

OBJECTIVE: The present study was undertaken to investigate whether Latina and African American women with arthritis-related knee pain and primary care providers who treat them believe their treatment decisions would benefit from having more information about the impact of treatment on their quality of life, medical care costs, and work productivity. METHODS: We conducted 4 focus groups of Latina and African American women over age 45 years who had knee pain. We also conducted 2 focus groups with primary care providers who treated Latina and African American women for knee pain. The participants were recruited from the community. They were asked their opinions about a decision tool that presented information on a range of treatment options and their impacts on quality of life, medical care costs, and work productivity. They were asked whether providing this information would help them make better treatment decisions. We analyzed the focus group transcripts using ATLAS.ti. RESULTS: We found that minority women and primary care providers endorsed the use of a decision-making tool that provided information of the impact of treatment on quality of life, medical care costs, and work productivity. Providers felt that patients would benefit from having the additional information but were concerned about its complexity and some patients' ability to comprehend the information. CONCLUSION: Latina and African American women could make more informed treatment decisions for their knee pain using a decision-making tool that provides them with significant information about how various treatment options may impact their quality of life, medical care costs, and workforce productivity.

Author Correction: Impacts of environmental and socio-economic factors on emergence and epidemic potential of Ebola in Africa.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Impacts of environmental and socio-economic factors on emergence and epidemic potential of Ebola in Africa.

Recent outbreaks of animal-borne emerging infectious diseases have likely been precipitated by a complex interplay of changing ecological, epidemiological and socio-economic factors. Here, we develop modelling methods that capture elements of each of these factors, to predict the risk of Ebola virus disease (EVD) across time and space. Our modelling results match previously-observed outbreak patterns with high accuracy, and suggest further outbreaks could occur across most of West and Central Africa. Trends in the underlying drivers of EVD risk suggest a 1.75 to 3.2-fold increase in the endemic rate of animal-human viral spill-overs in Africa by 2070, given current modes of healthcare intervention. Future global change scenarios with higher human population growth and lower rates of socio-economic development yield a fourfold higher likelihood of epidemics occurring as a result of spill-over events. Our modelling framework can be used to target interventions designed to reduce epidemic risk for many zoonotic diseases.

Outcomes of a nurse-led model of care for hepatitis C assessment and treatment with direct-acting antivirals in the custodial setting.

BACKGROUND: People in prison have been identified as an important population to prioritise for hepatitis C virus (HCV) treatment to achieve HCV elimination goals. We evaluated the efficacy of the New South Wales Justice Health and Forensic Mental Health Network Hepatitis Nurse Led Model of Care during the 12 months following the widespread availability of HCV direct acting antivirals (DAAs) in Australia. METHODS: A retrospective cohort study was conducted of a network of 36 correctional centres across NSW from April 2016 to March 2017, with approximately 13 000 full time inmates. Population Health Nurses conducted initial clinical assessments and confirmatory testing. Patients were referred to a Hepatitis Clinical Nurse Consultant (CNC) for protocol-driven assessment, including transient elastography to assess hepatic fibrosis. The CNC then discussed the case with an Infectious Diseases physician and DAA therapies were prescribed. The total number of patients who commenced and completed treatment, and sustained virological response 12 weeks post treatment completion (SVR 12) were recorded. RESULTS: During the first 12 months of DAA treatment 698 patients were commenced on HCV treatment. Of those who were tested at the 12-week post treatment completion timepoint the per-protocol SVR12 (cure) rate was 92% (396/430), with 34 patients having a detectable viral load. 52 (7%) patients were released to freedom before completing treatment and a further 211 (30%) were released prior to SVR12 assessment. These outcomes indicate an intention-to-treat SVR 12 cure rate of 57% (396/698). There were no differences in demographic or treatment characteristics between those who underwent SVR12 testing and those released prior. CONCLUSIONS: Treatment for HCV can be delivered safely, efficiently and in high numbers in the prison setting using a nurse-led model of care. This will be an important component of the strategy to eliminate HCV infection as a public health concern by 2030.

A Fresh Perspective on a Familiar Problem: Examining Disparities in Knee Osteoarthritis Using a Markov Model.

BACKGROUND: Disparities in the presentation of knee osteoarthritis (OA) and in the utilization of treatment across sex, racial, and ethnic groups in the United States are well documented. OBJECTIVES: We used a Markov model to calculate lifetime costs of knee OA treatment. We then used the model results to compute costs of disparities in treatment by race, ethnicity, sex, and socioeconomic status. RESEARCH DESIGN: We used the literature to construct a Markov Model of knee OA and publicly available data to create the model parameters and patient populations of interest. An expert panel of physicians, who treated a large number of patients with knee OA, constructed treatment pathways. Direct costs were based on the literature and indirect costs were derived from the Medical Expenditure Panel Survey. RESULTS: We found that failing to obtain effective treatment increased costs and limited benefits for all groups. Delaying treatment imposed a greater cost across all groups and decreased benefits. Lost income because of lower labor market productivity comprised a substantial proportion of the lifetime costs of knee OA. Population simulations demonstrated that as the diversity of the US population increases, the societal costs of racial and ethnic disparities in treatment utilization for knee OA will increase. CONCLUSIONS: Our results show that disparities in treatment of knee OA are costly. All stakeholders involved in treatment decisions for knee OA patients should consider costs associated with delaying and forgoing treatment, especially for disadvantaged populations. Such decisions may lead to higher costs and worse health outcomes.

One Health for a changing world: new perspectives from Africa.

The concept of One Health, which aims to drive improvements in human, animal and ecological health through an holistic approach, has been gaining increasing support and attention in recent years. While this concept has much appeal, there are few examples where it has been successfully put into practice. This Special Issue explores the challenges in African contexts, with papers looking at the complex interactions between ecosystems, diseases and poverty dynamics; at underlying social and political dimensions; at the potentials for integrative modelling; and at the changes in policy and practice required to realise a One Health approach. This introductory paper offers an overview of the 11 papers, coming from diverse disciplinary perspectives, that each explore how a One Health approach can work in a world of social, economic and environmental change.

Economic Evaluation of Vaccination Programmes in Older Adults and the Elderly: Important Issues and Challenges.

High-income countries are undergoing demographic transitions towards populations with substantial larger proportions of older adults. Due to the increased susceptibility of older adults to infectious diseases and their consequences, vaccination programmes are an important health intervention to help maintain healthy ageing. While much of the existing literature suggests that current vaccination programmes targeted at older adults and the elderly are likely to be cost effective in high-income countries, we argue that it is important to more fully consider some important issues and challenges. Since the majority of vaccines have been developed for children, economic evaluations of vaccination programmes have consequentially tended to focus on this age group and on how to incorporate herd-immunity effects. While programmes targeted at older adults and the elderly may also induce some herd effects, there are other important challenges to consider in these economic evaluations. For example, age and time effects in relation to vaccine efficacy and duration of immunity, as well as heterogeneity between targeted individuals in terms of risk of infection, severity of disease and response to vaccination. For some pathogens, there is also the potential for interactions with childhood programmes in the form of herd-immunity effects.

Household demography and early childhood mortality in a rice-farming village in Northern Laos.

This paper extends Alexandr Chayanov's model of changing household demography (specifically the ratio of food consumers to food producers) and its influence on agricultural behavior so that it includes possible adverse effects of a rising ratio on nutritional status and early childhood mortality within the household. We apply the model to 35 years' worth of longitudinal demographic and economic data collected in the irrigated-rice growing village of Na Savang in northern Laos. When appropriate controls are included for other household variables, unobserved inter-household heterogeneity, and changes in local conditions and national policy over the study period, the analysis suggests that a unit increase in the household's consumer/producer ratio induces something like a nine-fold increase in the risk of death among household members aged less than five years. Monte Carlo simulation studies suggest that this may be an over-estimate but also that the effect is probably real and likely to be an important factor in household demography. At the very least, the results suggest that Chayanov's model still has theoretical relevance and deserves to be revived.

Musculoskeletal health disparities: health literacy, cultural competency, informed consent, and shared decision making.

The factors that contribute to musculoskeletal healthcare disparities may influence the results of studies regarding the long-term outcome of orthopaedic implants. Patient decisions regarding their healthcare and their subsequent outcomes are influenced by health literacy. Providing patients with the information that they need to consent to treatment must be provided in a culturally competent manner. The influence of the physician or healthcare provider on the treatment choice varies depending on the type of decision-making process: patient-based, physician-based, or shared decision making. Respecting the patient's autonomy while acknowledging the knowledge and experience of the physician, we advocate for shared decision making. This may require modification of existing regulations regarding informed consent. Furthermore, federal and state directives have been put into place to address healthcare disparities, especially with respect to culturally competent care and access to proper healthcare.

Understanding the cost-effectiveness of influenza vaccination in children: methodological choices and seasonal variability.

BACKGROUND: The universal vaccination of children for influenza has recently been recommended in the UK and is being considered in other developed countries. OBJECTIVES: The aim of this study was to explore the potential costs and benefits of childhood influenza vaccination to gain a better understanding of the key drivers of cost-effectiveness. METHODS: As our case study we examined the cost-effectiveness of vaccination in Australian schoolchildren using an age-stratified Susceptible Exposed Infectious Recovered model. RESULTS: The results of this study highlight the critical role that methodological choices play in determining the cost-effectiveness of influenza vaccination. These choices include decisions about the structure of the model (including/excluding herd immunity) and what costs and benefits to include in the analysis. In scenarios where herd protection was included we estimated that the program was likely to be cost-effective. The study also illustrates the importance of the inherent seasonal variability of influenza, which can produce counter-intuitive results, with low transmission seasons being easier to control by vaccination but resulting in fewer benefits. CONCLUSIONS: Universal childhood influenza vaccination is likely to be cost-effective if a substantial herd protection effect can be achieved by the program. However, it is important that decision makers understand the role of seasonal variability and the impact of alternative methodological choices in economic evaluations of influenza vaccination.

Infant mortality and intra-household competition in the Northern Islands of Orkney, Scotland, 1855-2001.

This study applies principles from the theory of household life cycles to the study of early childhood mortality in the population of the Northern Orkney Islands, Scotland. The primary hypothesis is that unfavorable household economic conditions resulting from changes in household demographic composition increase the risk of death for children under the age of 5 years because of limited resources and intra-household competition. We apply Cox proportional hazards models to nearly 5,000 linked birth and death records from the Northern Orkney Islands, Scotland, from the period 1855 to 2001. The dependent variable is the child's risk of death before age 5. Findings suggest that children in households with unfavorable age compositions face higher risk of death. This elevated risk of death continues once heterogeneity among children, islands, and households is controlled. Results also show differential risk of death for male children, children of higher birth orders, and twin births. The analyses present evidence for intra-household competition in this historic setting. The most convincing evidence of competition is found in the effects of household consumer/producer ratios and twinning on child mortality risks.

Unresolved questions concerning the effectiveness of psychological assessment as a therapeutic intervention: comment on Poston and Hanson (2010).

In a recent article in this journal, Poston and Hanson (2010) reported a meta-analysis of 17 studies on the use of psychological assessment as a therapeutic intervention (PATI) and concluded that "psychological assessment procedures--when combined with personalized, collaborative, and highly involving test feedback--have positive, clinically meaningful effects on treatment" (Poston & Hanson, 2010, p. 203). Although extant data suggest that PATI can sometimes exert positive effects, Poston and Hanson's (2010) meta-analysis may overstate the magnitude of these effects because the authors (a) included several studies that combined assessment with treatment components that are irrelevant to PATI, sometimes rendering it impossible to attribute any observed effects to PATI per se and (b) excluded numerous nonsignificant results. Moreover, the studies Poston and Hanson (2010) reviewed neglected to rule out Barnum effects as alternative explanations for client improvement, raising the possibility that PATI works for reasons other than those proposed by its advocates. We conclude that Poston and Hanson's (2010) review leaves a number of lingering questions concerning the treatment utility of PATI unanswered.

The potential cost-effectiveness of infant pneumococcal vaccines in Australia.

Over the last decade infant pneumococcal vaccination has been adopted as part of routine immunisation schedules in many developed countries. Although highly successful in many settings such as Australia and the United States, rapid serotype replacement has occurred in some European countries. Recently two pneumococcal conjugate vaccines (PCVs) with extended serotype coverage have been licensed for use, a 10-valent (PHiD-CV) and a 13-valent (PCV-13) vaccine, and offer potential replacements for the existing vaccine (PCV-7) in Australia. To evaluate the cost-effectiveness of PCV programs we developed a static, deterministic state-transition model. The perspective for costs included those to the government and healthcare system. When compared to current practice (PCV-7) both vaccines offered potential benefits, with those estimated for PHiD-CV due primarily to prevention of otitis media and PCV-13 due to a further reduction in invasive disease in Australia. At equivalent total cost to vaccinate an infant, compared to no PCV the base-case cost per QALY saved were estimated at A$64,900 (current practice, PCV-7; 3+0), A$50,200 (PHiD-CV; 3+1) and A$55,300 (PCV-13; 3+0), respectively. However, assumptions regarding herd protection, serotype protection, otitis media efficacy, and vaccination cost changed the relative cost-effectiveness of alternative PCV programs. The high proportion of current invasive disease caused by serotype 19A (as included in PCV-13) may be a decisive factor in determining vaccine policy in Australia.