Economic Burden of Reported Lyme Disease in High-Incidence Areas, United States, 2014-2016.

Approximately 476,000 cases of Lyme disease are diagnosed in the United States annually, yet comprehensive economic evaluations are lacking. In a prospective study among reported cases in Lyme disease-endemic states, we estimated the total patient cost and total societal cost of the disease. In addition, we evaluated disease and demographic factors associated with total societal cost. Participants had a mean patient cost of ≈$1,200 (median $240) and a mean societal cost of ≈$2,000 (median $700). Patients with confirmed disseminated disease or probable disease had approximately double the societal cost of those with confirmed localized disease. The annual, aggregate cost of diagnosed Lyme disease could be $345-968 million (2016 US dollars) to US society. Our findings emphasize the importance of effective prevention and early diagnosis to reduce illness and associated costs. These results can be used in cost-effectiveness analyses of current and future prevention methods, such as a vaccine.

Cost-Effectiveness and Impact of a Targeted Age- and Incidence-based West Nile Virus Vaccine Strategy.

BACKGROUND: West Nile virus (WNV) is the leading cause of arboviral disease in the United States and is associated with significant morbidity and mortality. A previous analysis found that a vaccination program targeting persons aged ≥60 years was more cost-effective than universal vaccination, but costs remained high. METHODS: We used a mathematical Markov model to evaluate cost-effectiveness of an age- and incidence-based WNV vaccination program. We grouped states and large counties (≥100 000 persons aged ≥60 years) by median annual WNV incidence rates from 2004 to 2017 for persons aged ≥60 years. We defined WNV incidence thresholds, in increments of 0.5 cases per 100 000 persons ≥60 years. We calculated potential cost per WNV vaccine-prevented case and per quality adjusted life-years (QALYs) saved. RESULTS: Vaccinating persons aged ≥60 years in states with an annual incidence of WNV neuroinvasive disease of ≥0.5 per 100 000 resulted in approximately half the cost per health outcome averted compared to vaccinating persons aged ≥60 years in the contiguous United States. This approach could potentially prevent 37% of all neuroinvasive disease cases and 63% of WNV-related deaths nationally. Employing such a threshold at a county level further improved cost-effectiveness ratios while preventing 19% and 30% of WNV-related neuroinvasive disease cases and deaths, respectively. CONCLUSIONS: An age- and incidence-based WNV vaccination program could be a more cost-effective strategy than an age-based program while still having a substantial impact on lowering WNV-related morbidity and mortality.

Prevalence, clinical profile, and stroke risk of atrial fibrillation in rural Andhra Pradesh, India (The AP-AF study) - Rationale and design.

INTRODUCTION: The epidemiology of atrial fibrillation (AF) in India has not been studied systematically in large scale population based surveys. Stroke is one of the leading causes of death and disability in India. As AF is a major contributor of stroke, it is important to know the burden of AF and stroke risk in the population. The Andhra Pradesh Atrial Fibrillation (AP-AF) study aims to assess the prevalence, etiology, risk factors and stroke risk among the rural population in Andhra Pradesh, India. METHODS: This is a cross-sectional survey done using a two-stage sampling process. Adults (≥18years) from villages in East and West Godavari districts were sampled. Field investigators used a structured questionnaire to collect information on basic demographics, cardiovascular risk factors and medical history. Anthropometric measurements were performed, blood pressure measured and fasting capillary blood glucose was assessed. Electrocardiogram was done using a hand-held mobile ECG device-KardioMobile. ECGs were interpreted by study cardiologists. Participants diagnosed to have AF were invited to participate in a camp conducted by cardiologists where echocardiogram was done and also a focused history related to AF was collected. Along with age and sex stratified prevalence of AF, descriptive statistics will be used to present demographics, clinical profile, and cardiovascular risk factors. Stroke risk will be calculated using CHA 2 DS 2 -Vasc score. CONCLUSION: The AP-AF study is expected to provide important information on AF epidemiology in rural India. The information may help improve health care policies in preventing stroke and other complications of AF.

The Epidemiology of Foodborne Botulism Outbreaks: A Systematic Review.

Background: We performed a systematic review of foodborne botulism outbreaks to describe their clinical aspects and descriptive epidemiology in order to inform public health response strategies. Methods: We searched seven databases for reports of foodborne botulism outbreaks published in English from database inception to May 2015. We summarized descriptive characteristics and analyzed differences in exposure and toxin types by geographic region. We performed logistic regression to assess correlations between exposure source, implicated food, and outbreak size. Results: There were 197 outbreaks reported between 1920 and 2014. The median number of cases per outbreak was 3 (range 2-97). The majority of reported outbreaks (109; 55%) occurred in the United States. Toxin types A, B, E, and F were identified as the causative agent in 34%, 16%, 17%, and 1% of outbreaks, respectively. The median duration between exposure and symptom onset was approximately 1 day. The mean percentage of cases requiring mechanical ventilation per outbreak was 34%. Seventy percent of all outbreaks and 77% of small outbreaks (≤11 cases) originated from point source exposures, while commercial foods were significantly (odds ratio, 6.9; 95% confidence interval, 2.2-21.1) associated with large outbreaks (≥12 cases). Conclusions: Toxin type A accounted for half of outbreaks, and these outbreaks had a higher proportion of patient ventilatory failure. Most outbreaks were due to point source exposures, while outbreaks due to commercial food were larger. For effective responses to foodborne botulism outbreaks, these findings demonstrate the need for timely outbreak investigation and hospital surge capacity.

Potential demand for respirators and surgical masks during a hypothetical influenza pandemic in the United States.

BACKGROUND: To inform planning for an influenza pandemic, we estimated US demand for N95 filtering facepiece respirators (respirators) by healthcare and emergency services personnel and need for surgical masks by pandemic patients seeking care. METHODS: We used a spreadsheet-based model to estimate demand for 3 scenarios of respirator use: base case (usage approximately follows epidemic curve), intermediate demand (usage rises to epidemic peak and then remains constant), and maximum demand (all healthcare workers use respirators from pandemic onset). We assumed that in the base case scenario, up to 16 respirators would be required per day per intensive care unit patient and 8 per day per general ward patient. Outpatient healthcare workers and emergency services personnel would require 4 respirators per day. Patients would require 1.2 surgical masks per day. RESULTS AND CONCLUSIONS: Assuming that 20% to 30% of the population would become ill, 1.7 to 3.5 billion respirators would be needed in the base case scenario, 2.6 to 4.3 billion in the intermediate demand scenario, and up to 7.3 billion in the maximum demand scenario (for all scenarios, between 0.1 and 0.4 billion surgical masks would be required for patients). For pandemics with a lower attack rate and fewer cases (eg, 2009-like pandemic), the number of respirators needed would be higher because the pandemic would have longer duration. Providing these numbers of respirators and surgical masks represents a logistic challenge for US public health agencies. Public health officials must urgently consider alternative use strategies for respirators and surgical masks during a pandemic that may vary from current practices.

Regional spread of Ebola virus, West Africa, 2014.

To explain the spread of the 2014 Ebola epidemic in West Africa, and thus help with response planning, we analyzed publicly available data. We found that the risk for infection in an area can be predicted by case counts, population data, and distances between affected and nonaffected areas.

Incidence of Clinician-Diagnosed Lyme Disease, United States, 2005-2010.

National surveillance provides important information about Lyme disease (LD) but is subject to underreporting and variations in practice. Information is limited about the national epidemiology of LD from other sources. Retrospective analysis of a nationwide health insurance claims database identified patients from 2005-2010 with clinician-diagnosed LD using International Classification of Diseases, Ninth Revision, Clinical Modification, codes and antimicrobial drug prescriptions. Of 103,647,966 person-years, 985 inpatient admissions and 44,445 outpatient LD diagnoses were identified. Epidemiologic patterns were similar to US surveillance data overall. Outpatient incidence was highest among boys 5-9 years of age and persons of both sexes 60-64 years of age. On the basis of extrapolation to the US population and application of correction factors for coding, we estimate that annual incidence is 106.6 cases/100,000 persons and that ≈329,000 (95% credible interval 296,000-376,000) LD cases occur annually. LD is a major US public health problem that causes substantial use of health care resources.

Impact and cost-effectiveness evaluation of nutritional supplementation and complementary interventions for tuberculosis treatment outcomes under mukti pay-for-performance model in Madhya Pradesh, India: A study protocol.

Background: A."pay-for-performance" (P4P) intervention model for improved tuberculosis (TB) outcomes, called "Mukti," has been implemented in an underdeveloped tribal area of central India. The target of this project is to improve nutritional status, quality of life (QoL), and treatment outcomes of 1000 TB patients through four interventions: food baskets, personal counseling, peer-to-peer learning and facilitation for linkage to government schemes. The current study aims to assess the success of this model by evaluating its impact and cost-effectiveness using a quasi-experimental approach. Methods: Data for impact assessment have been collected from 1000 intervention and control patients. Study outcomes such as treatment completion, sputum negativity, weight gain, and health-related QoL will be compared between matched samples. Micro costing approach will be used for assessing the cost of routine TB services provision under the national program and the incremental cost of implementing our interventions. A decision and Markov hybrid model will estimate long-term costs and health outcomes associated with the use of study interventions. Measures of health outcomes will be mortality, morbidity, and disability. Cost-effectiveness will be assessed in terms of incremental cost per quality-adjusted life-years gained and cost per unit increase in patient weight in intervention versus control groups. Results: The evidence generated from the present study in terms of impact and cost-effectiveness estimates will thus help to identify not only the effectiveness of these interventions but also the optimal mode of financing such measures. Our estimates on scale-up costs for these interventions will also help the state and the national government to consider scale-up of such interventions in the entire state or country. Discussion: The study will generate important evidence on the impact of nutritional supplementation and other complementary interventions for TB treatment outcomes delivered through P4P financing models and on the cost of scaling up these to the state and national level in India.

Prevalence, clinical profile, and stroke risk of atrial fibrillation in rural Andhra Pradesh, India (the AP-AF study).

The burden of atrial fibrillation (AF) is increasing worldwide. It is often asymptomatic, with stroke being the first manifestation in some. AF burden in the community and the practice of stroke prophylaxis has not been studied in India. The problem might be higher in rural regions due to poor health awareness and challenges to healthcare access. This study aimed to estimate the prevalence of AF, clinical profile and stroke risk in rural India. METHODS: This is a community-based cross-sectional study done in rural Andhra Pradesh (AP). Adults from 40 villages formed the study population. We did a door-to door survey to collect information on demographics, and medical history. Electrocardiogram was recorded using a smart phone based Alivecor device. Participants diagnosed with AF underwent echocardiogram. Study cardiologists assessed the cardiovascular risk profile and collected detailed medical history. RESULTS: Fourteen of the 4281 individuals screened had AF (0.3%). The mean age of the sampled population was 44 ± 16.5 years with 56% women. The mean age of participants with AF was 71 ±7.8 years; males were 71%. Except for one, all were non-valvular AF. Majority had a CHA2D2S2Vasc score of ≥2. Three had history of stroke. Two were on anticoagulant therapy but without INR monitoring. CONCLUSION: The prevalence of AF is lower in this study compared to studies from the developed countries. Non-rheumatic cardiovascular risk factors were primary causes for AF. Non-adherence to stroke prophylaxis is a major threat that needs to be addressed.

Epidemiology and cost of Lyme disease-related hospitalizations among patients with employer-sponsored health insurance-United States, 2005-2014.

An estimated 300,000 cases of Lyme disease occur in the United States annually. Disseminated Lyme disease may result in carditis, arthritis, facial palsy or meningitis, sometimes requiring hospitalization. We describe the epidemiology and cost of Lyme disease-related hospitalizations. We analysed 2005-2014 data from the Truven Health Analytics MarketScan Commercial Claims and Encounters Databases to identify inpatient records associated with Lyme disease based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. We estimated the annual number and median cost of Lyme disease-related hospitalizations in the United States in persons under 65 years of age. Costs were adjusted to reflect 2016 dollars. Of 20,983,165 admission records contained in the inpatient databases during the study period, 2,823 (0.01%) met inclusion criteria for Lyme disease-related hospitalizations. Over half of the identified records contained an ICD-9-CM code for meningitis (n = 614), carditis (n = 429), facial palsy (n = 400) or arthritis (n = 377). Nearly 60% of hospitalized patients were male. The median cost per Lyme disease-related hospitalization was $11,688 (range: $140-$323,613). The manifestation with the highest median cost per stay was carditis ($17,461), followed by meningitis ($15,177), arthritis ($13,012) and facial palsy ($10,491). Median cost was highest among the 15- to 19-year-old age group ($12,991). Admissions occurring in January had the highest median cost ($13,777) for all study years. Based on extrapolation to the U.S. population, we estimate that 2,196 Lyme disease-related hospitalizations in persons under 65 years of age occur annually with an estimated annual cost of $25,826,237. Lyme disease is usually treated in an outpatient setting; however, some patients with Lyme disease require hospitalization, underscoring the need for effective prevention methods to mitigate these serious cases. Information from this analysis can aid economic evaluations of interventions that prevent infection and advances in disease detection.

Estimating dengue under-reporting in Puerto Rico using a multiplier model.

Dengue is a mosquito-borne viral illness that causes a variety of health outcomes, from a mild acute febrile illness to potentially fatal severe dengue. Between 2005 and 2010, the annual number of suspected dengue cases reported to the Passive Dengue Surveillance System (PDSS) in Puerto Rico ranged from 2,346 in 2006 to 22,496 in 2010. Like other passive surveillance systems, PDSS is subject to under-reporting. To estimate the degree of under-reporting in Puerto Rico, we built separate inpatient and outpatient probability-based multiplier models, using data from two different surveillance systems-PDSS and the enhanced dengue surveillance system (EDSS). We adjusted reported cases to account for sensitivity of diagnostic tests, specimens with indeterminate results, and differences between PDSS and EDSS in numbers of reported dengue cases. In addition, for outpatients, we adjusted for the fact that less than 100% of medical providers submit diagnostic specimens from suspected cases. We estimated that a multiplication factor of between 5 (for 2010 data) to 9 (for 2006 data) must be used to correct for the under-reporting of the number of laboratory-positive dengue inpatients. Multiplication factors of between 21 (for 2010 data) to 115 (for 2008 data) must be used to correct for the under-reporting of laboratory-positive dengue outpatients. We also estimated that, after correcting for underreporting, the mean annual rate, for 2005-2010, of medically attended dengue in Puerto Rico to be between 2.1 (for dengue inpatients) to 7.8 (for dengue outpatients) per 1,000 population. These estimated rates compare to the reported rates of 0.4 (dengue outpatients) to 0.1 (dengue inpatients) per 1,000 population. The multipliers, while subject to limitations, will help public health officials correct for underreporting of dengue cases, and thus better evaluate the cost-and-benefits of possible interventions.

Cost effectiveness of a targeted age-based West Nile virus vaccination program.

BACKGROUND: West Nile virus (WNV) is the leading cause of domestically-acquired arboviral disease in the United States. Several WNV vaccines are in various stages of development. We estimate the cost-effectiveness of WNV vaccination programs targeting groups at increased risk for severe WNV disease. METHODS: We used a mathematical model to estimate costs and health outcomes of vaccination with WNV vaccine compared to no vaccination among seven cohorts, spaced at 10year intervals from ages 10 to 70years, each followed until 90-years-old. U.S. surveillance data were used to estimate WNV neuroinvasive disease incidence. Data for WNV seroprevalence, acute and long-term care costs of WNV disease patients, quality-adjusted life-years (QALYs), and vaccine characteristics were obtained from published reports. We assumed vaccine efficacy to either last lifelong or for 10years with booster doses given every 10years. RESULTS: There was a statistically significant difference in cost-effectiveness ratios across cohorts in both models and all outcomes assessed (Kruskal-Wallis test p<0.0001). The 60-year-cohort had a mean cost per neuroinvasive disease case prevented of $664,000 and disability averted of $1,421,000 in lifelong model and $882,000 and $1,887,000, respectively in 10-year immunity model; these costs were statistically significantly lower than costs for other cohorts (p<0.0001). Vaccinating 70-year-olds had the lowest cost per death averted in both models at around $4.7 million (95%CI $2-$8 million). Cost per disease case averted was lowest among 40- and 50-year-old cohorts and cost per QALY saved lowest among 60-year cohorts in lifelong immunity model. The models were most sensitive to disease incidence, vaccine cost, and proportion of persons developing disease among infected. CONCLUSIONS: Age-based WNV vaccination program targeting those at higher risk for severe disease is more cost-effective than universal vaccination. Annual variation in WNV disease incidence, QALY weights, and vaccine costs impact the cost effectiveness ratios.

Modeling in Real Time During the Ebola Response.

To aid decision-making during CDC's response to the 2014-2016 Ebola virus disease (Ebola) epidemic in West Africa, CDC activated a Modeling Task Force to generate estimates on various topics related to the response in West Africa and the risk for importation of cases into the United States. Analysis of eight Ebola response modeling projects conducted during August 2014-July 2015 provided insight into the types of questions addressed by modeling, the impact of the estimates generated, and the difficulties encountered during the modeling. This time frame was selected to cover the three phases of the West African epidemic curve. Questions posed to the Modeling Task Force changed as the epidemic progressed. Initially, the task force was asked to estimate the number of cases that might occur if no interventions were implemented compared with cases that might occur if interventions were implemented; however, at the peak of the epidemic, the focus shifted to estimating resource needs for Ebola treatment units. Then, as the epidemic decelerated, requests for modeling changed to generating estimates of the potential number of sexually transmitted Ebola cases. Modeling to provide information for decision-making during the CDC Ebola response involved limited data, a short turnaround time, and difficulty communicating the modeling process, including assumptions and interpretation of results. Despite these challenges, modeling yielded estimates and projections that public health officials used to make key decisions regarding response strategy and resources required. The impact of modeling during the Ebola response demonstrates the usefulness of modeling in future responses, particularly in the early stages and when data are scarce. Future modeling can be enhanced by planning ahead for data needs and data sharing, and by open communication among modelers, scientists, and others to ensure that modeling and its limitations are more clearly understood. The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).

Initial and long-term costs of patients hospitalized with West Nile virus disease.

There are no published data on the economic burden for specific West Nile virus (WNV) clinical syndromes (i.e., fever, meningitis, encephalitis, and acute flaccid paralysis [AFP]). We estimated initial hospital and lost-productivity costs from 80 patients hospitalized with WNV disease in Colorado during 2003; 38 of these patients were followed for 5 years to determine long-term medical and lost-productivity costs. Initial costs were highest for patients with AFP (median $25,117; range $5,385-$283,381) and encephalitis (median $20,105; range $3,965-$324,167). Long-term costs were highest for patients with AFP (median $22,628; range $624-$439,945) and meningitis (median $10,556; range $0-$260,748). Extrapolating from this small cohort to national surveillance data, we estimated the total cumulative costs of reported WNV hospitalized cases from 1999 through 2012 to be $778 million (95% confidence interval $673 million-$1.01 billion). These estimates can be used in assessing the cost-effectiveness of interventions to prevent WNV disease.

Economic and health impacts associated with a Salmonella Typhimurium drinking water outbreak-Alamosa, CO, 2008.

In 2008, a large Salmonella outbreak caused by contamination of the municipal drinking water supply occurred in Alamosa, Colorado. The objectives of this assessment were to determine the full economic costs associated with the outbreak and the long-term health impacts on the community of Alamosa. We conducted a postal survey of City of Alamosa (2008 population: 8,746) households and businesses, and conducted in-depth interviews with local, state, and nongovernmental agencies, and City of Alamosa healthcare facilities and schools to assess the economic and long-term health impacts of the outbreak. Twenty-one percent of household survey respondents (n = 369/1,732) reported diarrheal illness during the outbreak. Of those, 29% (n = 108) reported experiencing potential long-term health consequences. Most households (n = 699/771, 91%) reported municipal water as their main drinking water source at home before the outbreak; afterwards, only 30% (n = 233) drank unfiltered municipal tap water. The outbreak's estimated total cost to residents and businesses of Alamosa using a Monte Carlo simulation model (10,000 iterations) was approximately $1.5 million dollars (range: $196,677-$6,002,879), and rose to $2.6 million dollars (range: $1,123,471-$7,792,973) with the inclusion of outbreak response costs to local, state and nongovernmental agencies and City of Alamosa healthcare facilities and schools. This investigation documents the significant economic and health impacts associated with waterborne disease outbreaks and highlights the potential for loss of trust in public water systems following such outbreaks.

Potential intussusception risk versus benefits of rotavirus vaccination in the United States.

BACKGROUND: International data show a low-level increased risk of intussusception associated with rotavirus vaccination. Although US data have not documented a risk, we assumed a risk similar to international settings and compared potential vaccine-associated intussusception cases with benefits of prevention of rotavirus gastroenteritis by a fully implemented US rotavirus vaccine program. METHODS: To calculate excess intussusception cases, we used national data on vaccine coverage and baseline intussusception rates, and assumed a vaccine-associated intussusception relative risk of 5.3 (95% confidence interval [CI]: 3.0-9.3) in the first week after the first vaccine dose, the risk seen in international settings. We used postlicensure vaccine effectiveness data to calculate rotavirus disease burden averted. RESULTS: For a US birth cohort of 4.3 million infants, vaccine-associated intussusception could cause an excess 0.2 (range: 0.1-0.3) deaths, 45 (range: 21-86) hospitalizations and 13 (range: 6-25) cases managed in short-stay or emergency department settings. Vaccination would avert 14 (95% CI: 10-19) rotavirus-associated deaths, 53,444 (95% CI: 37,622-72,882) hospitalizations and 169,949 (95% CI: 118,161-238,630) emergency department visits. Summary benefit-risk ratios for death and hospitalization are 71:1 and 1093:1, respectively. CONCLUSIONS: The burden of severe rotavirus disease averted due to vaccination compared with the vaccine-associated intussusception events offers a side-by-side analysis of the benefits and potential risks. If an intussusception risk similar to that seen internationally exists in the United States, it is substantially exceeded by the benefits of rotavirus disease burden averted by vaccination.

Screening for refractive error and fitting with spectacles in rural and urban India: cost-effectiveness.

OBJECTIVES: To assess the cost-effectiveness of screening for refractive error and fitting with glasses in India. METHODS: We populated a decision tree with the costs of screening and spectacles, prevalence of varying levels of presenting and best corrected visual acuity (BCVA) from two studies, and sensitivity and specificity of screening. We calculated dollars spent per disability adjusted life year (DALY) averted separately in urban and rural areas for school-based screening (SBS) and primary eye care (PEC) programs that fit spectacles to individuals presenting for care. We conducted a series of univariate and probabilistic sensitivity analyses. An intervention was inferred to be highly cost-effective if the incremental cost-effectiveness ratio (ICER) was less than the gross domestic product (GDP) per capita and moderately cost-effective if the ICER was less than three times this level. RESULTS: Compared with no screening, urban SBS was highly cost-effective; rural SBS was moderately cost-effective for ages 5-15 and highly cost-effective for ages 7-15. Both urban and rural PEC were moderately cost-effective in comparison to SBS. Probabilistic sensitivity analysis suggested that SBS is likely the most cost-effective solution for refractive error in India if the 5-15 year old age group is targeted; primary eye care is the best choice if a high value is placed on DALYs and the 7-15 year old age group is targeted. CONCLUSION: Both SBS and PEC Interventions for refractive error can be considered cost-effective in India. Which is the more cost-effective depends on the choice of targeted age group and area of the intervention.