Cost-benefit analysis of Chlamydia trachomatis screening in pregnant women in a high burden setting in the United States.

BACKGROUND: Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI) in the United States (U.S.) [1] and remains a major public health problem. We determined the cost- benefit of screening all pregnant women aged 15-24 for Chlamydia trachomatis infection compared with no screening. METHODS: We developed a decision analysis model to estimate costs and health-related effects of screening pregnant women for C. trachomatis in a high burden setting (Brooklyn, NY). Outcome data was from literature for pregnant women in the 2015 US population. A virtual cohort of 6,444,686 pregnant women, followed for 1 year was utilized. Using outcomes data from the literature, we predicted the number of C. trachomatis cases, associated morbidity, and related costs. Two comparison arms were developed: pregnant women who received chlamydia screening, and those who did not. Costs and morbidity of a pregnant woman-infant pair with C. trachomatis were calculated and compared. RESULTS: Cost and benefit of screening relied on the prevalence of C. trachomatis; when rates are above 16.9%, screening was proven to offer net cost savings. At a pre-screening era prevalence of 8%, a screening program has an increased expense of $124.65 million ($19.34/individual), with 328 thousand more cases of chlamydia treated, and significant reduction in morbidity. At a current estimate of prevalence, 6.7%, net expenditure for screening is $249.08 million ($38.65/individual), with 204.63 thousand cases of treated chlamydia and reduced morbidity. CONCLUSIONS: Considering a high prevalence region, prenatal screening for C. trachomatis resulted in increased expenditure, with a significant reduction in morbidity to woman-infant pairs. Screening programs are appropriate if the cost per individual is deemed acceptable to prevent the morbidity associated with C. trachomatis.

Interventions to reduce repetitive ordering of low-value inpatient laboratory tests: a systematic review.

BACKGROUND: Over-ordering of daily laboratory tests adversely affects patient care through hospital-acquired anaemia, patient discomfort, burden on front-line staff and unnecessary downstream testing. This remains a prevalent issue despite the 2013 Choosing Wisely recommendation to minimise unnecessary daily labs. We conducted a systematic review of the literature to identify interventions targeting unnecessary laboratory testing. METHODS: We systematically searched MEDLINE, EMBASE, Cochrane Central and SCOPUS databases to identify interventions focused on reducing daily complete blood count, complete metabolic panel and basic metabolic panel labs. We defined interventions as 'effective' if a statistically significant reduction was attained and 'highly effective' if a reduction of ≥25% was attained. RESULTS: The search yielded 5646 studies with 41 articles that met inclusion criteria. We grouped interventions into one or more categories: audit and feedback, cost display, education, electronic medical record (EMR) change, and policy change. Most interventions lasted less than a year and used a multipronged approach. All five strategies were effective in most studies with EMR change being the most commonly used independent strategy. EMR change and policy change were the strategies most frequently reported as effective. EMR change was the strategy most frequently reported as highly effective. CONCLUSION: Our analysis identified five categories of interventions targeting daily laboratory testing. All categories were effective in most studies, with EMR change being most frequently highly effective. PROSPERO REGISTRATION NUMBER: CRD42021254076.

SARS-CoV-2 Infection and Associated Rates of Diabetic Ketoacidosis in a New York City Emergency Department.

INTRODUCTION: In early March 2020, coronavirus 2019 (COVID-19) spread rapidly in New York City. Shortly thereafter, in response to the shelter-in-place orders and concern for infection, emergency department (ED) volumes decreased. While a connection between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hyperglycemia/insulin deficiency is well described, its direct relation to diabetic ketoacidosis (DKA) is not. In this study we describe trends in ED volume and admitted patient diagnoses of DKA among five of our health system's EDs, as they relate to peak SARS-CoV-2 activity in New York City. METHODS: For the five EDs in our hospital system, deidentified visit data extracted for routine quality review was made available for analysis. We looked at total visits and select visit diagnoses related to DKA, across the months of March, April and May 2019, and compared those counts to the same period in 2020. RESULTS: A total of 93,218 visits were recorded across our five EDs from March 1-May 31, 2019. During that period there were 106 diagnoses of DKA made in the EDs (0.114% of visits). Across the same period in 2020 there were 59,009 visits, and 214 diagnoses of DKA (0.363% of visits) CONCLUSION: Despite a decrease in ED volume of 26.9% across our system during this time period, net cases of DKA diagnoses rose drastically by 70.1% compared to the prior year.

Cost-Benefit Analysis of a Chlamydia trachomatis Vaccine Program in Adolescent Girls in the United States.

BACKGROUND: With >1.4 million cases in the United States reported to the Centers for Disease Control and Prevention in 2012, Chlamydia trachomatis infection is a major public health concern. We examined the impact of a C trachomatis vaccination program using a decision-analysis model to estimate the effects of vaccination on C trachomatis-associated costs and morbidity. METHODS: We developed a Markov model considering a cohort of 2158117 US females aged 9 to 26 years. Morbidity, death, and healthcare-associated costs associated with chlamydial infection of mothers and fetuses/neonates were calculated over a 17-year time frame. We developed 2 major comparison arms, namely, a C trachomatis vaccination program and no C trachomatis vaccination program. Base-case efficacy and coverage were set to those of human papillomavirus in the United States with all variables, including efficacy and coverage, ranged in sensitivity analyses. RESULTS: On the basis of a base-case analysis, a vaccination program would cost an estimated $710 million for a cohort of 2158117 women over a 17-year period, an increase of $41 million over having no vaccination program. A vaccination program would prevent 34000 cases of C trachomatis infection and 5976 cases of pelvic inflammatory disease. CONCLUSIONS: A C trachomatis vaccination program results in increased cost to the healthcare system but averts significant morbidity and death.

Chlamydia pneumoniae-induced tumour necrosis factor alpha responses are lower in children with asthma compared with non-asthma.

INTRODUCTION: Chlamydia pneumoniae respiratory tract infection has been implicated in the pathogenesis of reactive airway disease and asthma. Innate cytokine responses that are protective of infection with intracellular pathogens may be impaired in patients with asthma. Tumour necrosis factor alpha (TNF-α) is a cytokine related to functions of monocytes and may inhibit C. pneumoniae infection. We investigated TNF-α responses in C. pneumoniae-infected peripheral blood mononuclear cells (PBMCs) in patients with asthma and non-asthma, and whether ciprofloxacin, azithromycin or doxycycline affects TNF-α responses. METHODS: PBMC (1.5×106) from paediatric patients with asthma (n=19) and non-asthmatic controls (n=6) were infected or mock infected for 1 hour with or without C. pneumoniae AR-39 at a multiplicity of infection=0.1, and cultured+ciprofloxacin, azithromycin or doxycycline (0.1 ug/mL) for 48 hours. TNF-α levels were measured in supernatants by ELISA. RESULTS: When PBMC from patients with asthma were infected with C. pneumoniae, levels of TNF-α were significantly lower than in subjects without asthma (48 hours) (5.5±5.6, 38.4±53.7; p=0.0113). However, baseline responses (no infection with C. pneumoniae) were similar in asthma and non-asthma (1.0±1.7, 1.1±1.2; p=0.89). When PBMC frompatiens with asthma were infected with C. pneumoniae+ciprofloxacin, azithromycin or doxycycline, TNF-α levels increased (25%-45%); this affect was not observed in PBMC from patients without asthma. CONCLUSIONS: We identified differences in the quantity of TNF-α produced by C. pneumoniae-infected PBMC in asthma compared with non-asthma.

The Cost-effectiveness of Varicella Zoster Virus Vaccination Considering Late Onset Asthma.

BACKGROUND: Recent studies reported that infection by varicella zoster virus (VZV) may lead to delayed onset of asthma in children/adolescents. This information will likely alter the cost-effectiveness of the US. VZV vaccination program. We created a decision analysis model to estimate the costs and health-related effects of VZV 2-dose vaccination, assuming VZV infection delays asthma onset. METHODS: The Markov model considered a birth cohort of 3,957,577 individuals entering the population from a societal perspective. We predicted the number of asthma/VZV cases, asthma-/VZV-related mortality and costs associated with asthma/VZV. Comparison arms included (1) VZV vaccination program without delayed asthma onset, (2) VZV vaccination program with delayed asthma onset and (3) no VZV vaccination program with delayed asthma onset. We considered delayed onset ranging from 3 to 12 years. RESULTS: The vaccination program proved cost-effective without an assumed delay in asthma onset. When the vaccination and no-vaccination arms were compared assuming delayed asthma onset, vaccination remained less costly despite increased savings related to asthma without vaccination. With delayed asthma onset of 9 years post VZV infection, cost savings due to vaccination were $914.09 million, with 9984 cases of asthma averted and 9 greater overall deaths with vaccination. CONCLUSION: VZV vaccination program was less costly than the "no-vaccination" scenario, despite delayed onset of asthma post VZV infection. However, vaccination resulted in increased asthma morbidity and mortality. This adds to current evidence that VZV vaccination is cost-effective, and may alter asthma-related health-care outcomes. VZV's effect on asthma symptoms still needs further evaluation before firm conclusions can be reached.

Cost-effectiveness analysis of Chlamydia trachomatis screening in Dutch pregnant women.

Chlamydia trachomatis infections during pregnancy may have serious consequences for women and their offspring. Chlamydial infections are largely asymptomatic. Hence, prevention is based on screening. The objective of this study was to estimate the cost-effectiveness of C. trachomatis screening during pregnancy. We used a health-economic decision analysis model, which included potential health outcomes of C. trachomatis infection for women, partners and infants, and premature delivery. We estimated the cost-effectiveness from a societal perspective using recent prevalence data from a population-based prospective cohort study among pregnant women in the Netherlands. We calculated the averted costs by linking health outcomes with health care costs and productivity losses. Cost-effectiveness was expressed as net costs per major outcome prevented and was estimated in base-case analysis, sensitivity, and scenario analysis. In the base-case analysis, the costs to detect 1000 pregnant women with C. trachomatis were estimated at €527,900. Prevention of adverse health outcomes averted €626,800 in medical costs, resulting in net cost savings. Sensitivity analysis showed that net cost savings remained with test costs up to €22 (test price €19) for a broad range of variation in underlying assumptions. Scenario analysis showed even more cost savings with targeted screening for women less than 30 years of age or with first pregnancies only. Antenatal screening for C. trachomatis is a cost-saving intervention when testing all pregnant women in the Netherlands. Savings increase even further when testing women younger than 30 years of age or with pregnancies only.

Potential cost-effectiveness of a new infant tuberculosis vaccine in South Africa--implications for clinical trials: a decision analysis.

Novel tuberculosis vaccines are in varying stages of pre-clinical and clinical development. This study seeks to estimate the potential cost-effectiveness of a BCG booster vaccine, while accounting for costs of large-scale clinical trials, using the MVA85A vaccine as a case study for estimating potential costs. We conducted a decision analysis from the societal perspective, using a 10-year time frame and a 3% discount rate. We predicted active tuberculosis cases and tuberculosis-related costs for a hypothetical cohort of 960,763 South African newborns (total born in 2009). We compared neonatal vaccination with bacille Calmette-Guérin alone to vaccination with bacille Calmette-Guérin plus a booster vaccine at 4 months. We considered booster efficacy estimates ranging from 40% to 70%, relative to bacille Calmette-Guérin alone. We accounted for the costs of Phase III clinical trials. The booster vaccine was assumed to prevent progression to active tuberculosis after childhood infection, with protection decreasing linearly over 10 years. Trial costs were prorated to South Africa's global share of bacille Calmette-Guérin vaccination. Vaccination with bacille Calmette-Guérin alone resulted in estimated tuberculosis-related costs of $89.91 million 2012 USD, and 13,610 tuberculosis cases in the birth cohort, over the 10 years. Addition of the booster resulted in estimated cost savings of $7.69-$16.68 million USD, and 2,800-4,160 cases averted, for assumed efficacy values ranging from 40%-70%. A booster tuberculosis vaccine in infancy may result in net societal cost savings as well as fewer active tuberculosis cases, even if efficacy is relatively modest and large scale Phase III studies are required.