Impact of quadrivalent influenza vaccines in Brazil: a cost-effectiveness analysis using an influenza transmission model.

BACKGROUND: Influenza epidemics significantly weight on the Brazilian healthcare system and its society. Public health authorities have progressively expanded recommendations for vaccination against influenza, particularly to the pediatric population. However, the potential mismatch between the trivalent influenza vaccine (TIV) strains and those circulating during the season remains an issue. Quadrivalent vaccines improves vaccines effectiveness by preventing any potential mismatch on influenza B lineages. METHODS: We evaluate the public health and economic benefits of the switch from TIV to QIV for the pediatric influenza recommendation (6mo-5yo) by using a dynamic epidemiological model able to consider the indirect impact of vaccination. Results of the epidemiological model are then imputed in a health-economic model adapted to the Brazilian context. We perform deterministic and probabilistic sensitivity analysis to account for both epidemiological and economical sources of uncertainty. RESULTS: Our results show that switching from TIV to QIV in the Brazilian pediatric population would prevent 406,600 symptomatic cases, 11,300 hospitalizations and almost 400 deaths by influenza season. This strategy would save 3400 life-years yearly for an incremental direct cost of R$169 million per year, down to R$86 million from a societal perspective. Incremental cost-effectiveness ratios for the switch would be R$49,700 per life-year saved and R$26,800 per quality-adjusted life-year gained from a public payer perspective, and even more cost-effective from a societal perspective. Our results are qualitatively similar in our sensitivity analysis. CONCLUSIONS: Our analysis shows that switching from TIV to QIV to protect children aged 6mo to 5yo in the Brazilian influenza epidemiological context could have a strong public health impact and represent a cost-effective strategy from a public payer perspective, and a highly cost-effective one from a societal perspective.

Public health and budget impacts of switching from a trivalent to a quadrivalent inactivated influenza vaccine in Paraguay.

This study aimed to investigate the public health and economic benefit of using a quadrivalent influenza vaccine (QIV) instead of a trivalent influenza vaccine (TIV) in past seasons in Paraguay. The budget impact of switching from TIV to QIV in the Immunization Program was also evaluated. The adapted model includes two modules. The first compared retrospectively Health and Economic outcomes resulting from the use of QIV instead of TIV. The second forecast the spending and savings that would be associated with the switch from TIV to QIV. Our findings estimate that the switch from TIV to QIV during the seasons 2012 to 2017 could have prevented around 2,600 influenza cases, 67 hospitalizations and 10 deaths. An alternative scenario using standardized estimates of the burden of influenza showed that 234 influenza-related hospitalizations and 29 deaths could have been prevented. The estimated annual budget impact of a full switch from TIV to QIV was around USD1,6 million both from the payer and societal perspectives. Those results are mainly driven by vaccine prices and coverage rate. In sum, this manuscript describes how the use of QIV instead of TIV could have prevented influenza cases and subsequent complications that led to hospitalizations and deaths. This could have generated savings for the health system and society, offsetting part of the additional investment needed to switch from TIV to QIV.

Switching from trivalent to quadrivalent inactivated influenza vaccines in Uruguay: a cost-effectiveness analysis.

We evaluated the cost-utility of replacing trivalent influenza vaccine (TIV) with quadrivalent influenza vaccine (QIV) in the current target populations in Uruguay. An existing decision-analytic static cost-effectiveness model was adapted for Uruguay. The population was stratified into age groups. Costs and outcomes were estimated for an average influenza season, based on observed rates from 2013 to 2019 inclusive. Introducing QIV instead of TIV in Uruguay would avoid around 740 additional influenza cases, 500 GP consultations, 15 hospitalizations, and three deaths, and save around 300 workdays, for the same vaccination coverage during an average influenza season. Most of the influenza-related consultations and hospitalizations would be avoided among children ≤4 and adults ≥65 years of age. Using QIV rather than TIV would cost an additional ~US$729,000, but this would be partially offset by savings in consultations and hospitalization costs. The incremental cost per quality-adjusted life-year (QALY) gained with QIV would be in the order of US$18,000 for both the payor and societal perspectives, for all age groups, and around US$12,000 for adults ≥65 years of age. The main drivers influencing the incremental cost-effectiveness ratio were the vaccine efficacy against the B strains and the percentage of match each season with the B strain included in TIV. Probabilistic sensitivity analysis showed that switching to QIV would provide a favorable cost-utility ratio for 50% of simulations at a willingness-to-pay per QALY of US$20,000. A switch to QIV is expected to be cost-effective for the current target populations in Uruguay, particularly for older adults.

Cost-effectiveness analysis of switching from a trivalent to a quadrivalent inactivated influenza vaccine in the Peruvian immunisation programme.

BACKGROUND: Seasonal influenza is an acute respiratory infection mostly caused by type A and B influenza viruses. The severe form of the infection can be life-threatening and lead to a significant burden. Vaccination is the most efficient way of preventing influenza infections and limit this burden. OBJECTIVES: To assess the cost-effectiveness of switching from a trivalent influenza vaccine (TIV) to a quadrivalent influenza vaccine (QIV) in the vaccination programme in Peru, and to evaluate the health and economic impact of reaching the vaccination coverage rate targeted by the Ministry of Health. METHODS: A decision-analytic static cost-effectiveness model, was adapted to the Peruvian setting under both payer and societal perspectives. RESULTS: A switch from TIV to QIV would prevent 29,126 additional cases (including 12,815 consultations), 54 hospitalisations, and 23 deaths related to influenza, mostly in the population <2 years-old and >60 years-old. This would lead to a saving of US $505,206 under the payer perspective, that would partially offset the investment necessary to introduce QIV into the immunisation programme. The resulting incremental cost-effectiveness ratio (ICER) is $16,649 per QALYs gained. The main drivers of the model results were vaccine efficacy against influenza B viruses, degree of match, vaccines prices and proportion of cases attributable to influenza B. The robustness of the results seems satisfactory as QIV has the probability of being a cost-effective strategy of 83.8% (considering a threshold of three GDP per capita). Reaching the coverage targeted by the Ministry of Health would result in health benefits and disease management savings, and lower ICERs. CONCLUSION: Introducing QIV instead of TIV in the Peruvian immunisation programme is expected to be a cost-effective strategy, especially in younger children and the elderly. The benefit of QIV would be even more important if the coverage targeted by the Ministry of Health would be reached in the most vulnerable groups.

Cost-Minimization and Budget Impact Analysis of a Hexavalent Vaccine (Hexaxim®) in the Colombian Expanded Program on Immunization.

OBJECTIVES: To evaluate cost implications of a hexavalent vaccine (diphtheria, tetanus, and acellular pertussis [DTaP]-inactivated polio vaccine [IPV]-hepatitis B [HB]-Haemophilus influenzae type B [Hib] polysaccharide conjugated to T protein [PRP∼T]) as an alternative to DT-whole-cell pertussis (wP)-HB//Hib, DTwP, IPV, and oral polio vaccines in the Expanded Program on Immunization schedule in Colombia. METHODS: Primary vaccination (DTaP-IPV-HB-PRP∼T or DTwP-HB-Hib + IPV [2, 4, 6 months]) and booster (DTaP-IPV-HB-PRP∼T or DTwP + oral polio vaccine [18 months]) (scenario 1) and primary vaccination only (DTaP-IPV-HB-PRP∼T or DTwP-HB-Hib + IPV) (scenario 2) were evaluated. An estimated cost-minimization analysis was based on a micro costing technique for vaccination-associated activities. Adverse event (AE)-associated costs, out-of-pocket costs, and productivity losses for caregivers were included. A budget impact (12-month temporal horizon) was estimated according to the distribution of full-term and premature infants. A 5% annual discount rate was used. A 2-way univariate (tornado) analysis evaluated which variables had the greatest impact on the overall cost. RESULTS: DTaP-IPV-HB-PRP∼T resulted in a cost increase of 29.38% (scenario 1) and 22.19% (scenario 2) for full-term infants and a decrease of 0.99% (scenario 1) and 18.88% (scenario 2) for premature infants, probably because of the higher incidence of wP-related AEs and associated costs in premature infants. With a 100% replacement rate, the budget impact for full-term infants and full-term plus premature infants was 23.73% and 21.80% (scenario 1), respectively, and 13.02% and 11.14% (scenario 2), respectively, of the national immunization program budget. The variables with most impact were the hexavalent vaccine price and costs associated with the pentavalent safety profile. CONCLUSIONS: Incorporation of the hexavalent vaccine in the Expanded Program on Immunization schedule would lead to an increase in spending largely mitigated by reduced AE incidence and reduced logistic and social costs.

Public health and economic impact of switching from a trivalent to a quadrivalent inactivated influenza vaccine in Mexico.

Most influenza vaccines in Mexico are trivalent, containing two influenza A strains and a single B strain. Quadrivalent influenza vaccines (QIVs) extend protection by including an additional B strain to cover both co-circulating B lineages. Here, we retrospectively estimated how a switch to QIV in Mexico would have impacted influenza-related health outcomes over the 2010/2011 to 2015/2016 influenza seasons, and prospectively estimated the budget impact of using QIV in Mexico's national immunization program from 2016/2017 to 2020/2021. For the retrospective estimation, we used an age-stratified static model incorporating Mexico-specific input parameters. For the prospective estimation, we used a budget impact model based on retrospective attack rates considering predicted future vaccination coverage. Between 2010/2011 and 2015/2016, a switch to QIV would have prevented 270,596 additional influenza cases, 102,000 general practitioner consultations, 140,062 days of absenteeism, 3,323 hospitalizations, and 312 deaths, saving Mex$214 million (US$10.8 million) in third-party payer costs. In the prospective analysis, a switch to QIV was estimated to prevent an additional 225,497 influenza cases, 85,000 general practitioner consultations, 116,718 days of absenteeism, 2,769 hospitalizations, and 260 deaths, saving Mex$178 million (US$9 million) in third-party payer costs over 5 years. Compared to the trivalent vaccine, the benefit and costs saved with QIV were sensitive to the distribution of influenza A vs. B cases and trivalent vaccine effectiveness against the mismatched B strain. These results suggest switching to QIV in Mexico would benefit healthcare providers and society by preventing influenza cases, morbidity, and deaths, and reducing associated use of medical resources.

Vínculos, autonomía y salud mental en adultos jóvenes del proceso de reintegración en Colombia / Bonds, autonomy and mental health in young adults of the reintegration process in Colombia

Este artículo busca explorar la construcción de los vínculos, su relación con el desarrollo de la autonomía y las problemáticas de salud mental de adultos jóvenes excombatientes de grupos armados que hacen parte del proceso de reintegración en Colombia. Se analizaron 3977 registros de la Encuesta Multimodal Psicosocial (EMP) correspondientes a adultos jóvenes entre los 18 y 24 años, que fueron aplicadas en desarrollo del proceso de reincorporación. Se aplicaron dos métodos de análisis estadísticos complementarios: el método de Componentes Principales (ACP) y un método Jerárquico aglomerativo. En el análisis de los procesos vinculares se encontró que en un grupo alrededor de un 80 % de los casos registra haber experimentado rupturas vinculares importantes a causa de la violencia, el abandono temprano y/o vivir en contextos de conflicto y violencia. En cuanto al análisis de los procesos de autonomía, se encontró que un grupo correspondiente al 70 % reporta no contar con las capacidades para garantizar su autonomía y calidad de vida, pasando por condiciones de precarización laboral con riesgo a incurrir en redes de delincuencia. Y un 39 % reporta coincidir alta disposición de riesgo en sus procesos vinculares y de autonomía.

This article seeks to explore the construction of bonds, their relation with the development of autonomy and the mental health problems of young adult ex-combatants of armed groups who are part of the reintegration process in Colombia. A total of 3977 records of the Psychosocial Multimodal Questionnaire (PMS) corresponding to young adults between 18 and 24 years old, which were applied in the development of the reincorporation process, were analyzed. Two complementary statistical analysis methods were applied: The Principal Components Method (PCA) and an agglomerative Hierarchical method. In the analysis of bonding processes, it was found that, in one group, about 80% of the cases recorded having experienced significant bonding ruptures due to violence, early abandonment and/or living in contexts of conflict and violence. Regarding the analysis of the processes of autonomy, a group corresponding to 70% reported not having the capacities to guarantee their autonomy and quality of life, going through conditions of job insecurity with the risk of incurring in criminal networks. And 39% report a high risk disposition in their relationship and autonomy processes.

Public health impact and economic benefits of quadrivalent influenza vaccine in Latin America.

Annual trivalent influenza vaccines (TIV) containing 2 A strains and one B lineage have been recommended for the prevention of influenza in most of Latin American countries. However, the circulation of 2 B lineages (Victoria and Yamagata) and difficulties in predicting the predominating lineage have led to the development of quadrivalent influenza vaccines (QIV), including both B lineages. Thus, the objective was to estimate the public health impact and influenza-related costs if QIV would have been used instead of TIV in 3 Latin American countries. We used a static model over the seasons 2010-2014 in Brazil, 2007-2014 in Colombia and 2006-2014 in Panama, focusing on population groups targeted by local vaccination recommendations: young children, adults with risk factors and the elderly. In Brazil, between 2010 and 2014, using QIV instead of TIV would have avoided US$ 6,200 per 100,000 person-years in societal costs, based on 168 influenza cases, 89 consultations, 3.2 hospitalizations and 0.38 deaths per 100,000 person-years. In Colombia and Panama, these would have ranged from US$ 1,000 to 12,700 (based on 34 cases, 13-25 consultations, 0.6-8.9 hospitalizations and 0.04-1.74 deaths) and from US$ 3,000 to 33,700 (based on 113 cases, 55-82 consultations, 0.5-27.8 hospitalizations and 0.08-6.87 deaths) per 100,000 person-years, respectively. Overall, the broader protection offered by QIV would have reduced the influenza humanistic and economic burden in the 3 countries. Despite the lack of local data leading to several extrapolations, this study is the first to give quantitative estimates of the potential benefits of QIV in Latin America.

Costing Dengue Fever Cases and Outbreaks: Recommendations from a Costing Dengue Working Group in the Americas.

OBJECTIVES: The overall aim of this article was to present a step-by-step guideline for determining the costs associated with dengue in dengue-endemic countries of the Latin American and the Caribbean region and to illustrate how each of these steps can be applied in dengue costing studies. METHODS: An expert panel was convened to develop standards for costing dengue so that over the next decade, decision makers will have access to improved information on the true cost of dengue in endemic countries of the Latin American and the Caribbean region. We described the outcome of the expert panel meeting, which resulted in the provision of a step-by-step dengue costing guideline that aims to provide direction to planners and program managers on how to estimate dengue economic burden studies, and provide a discussion forum of the methods used to cost dengue fever cases and outbreaks in a manner that should be accessible to persons with some familiarity with a cost study. RESULTS: The guideline includes nine sequential steps: 1) definition of the scope of the study; 2) identification of the target population; 3) description of the study perspective; 4) definition of the time horizon; 5) calculation of the sample size; 6) definition of the unit of analysis; 7) identification of the cost items; 8) measurement and valuation of the cost items; and 9) handling of uncertainty. The trade-off between accurate, patient-level cost estimates and data availability constraints is discussed. CONCLUSIONS: The current guideline is the result of constructive collaboration among a multidisciplinary research team to better ascertain the true economic burden of dengue across countries of the region.

Prevalencia y factores de riesgo de obesidad en adolescentes Policlínico René Vallejo Ortiz. Manzanillo. 2016-2017 / Prevalence and risk factors for obesity in adolescents René Vallejo Ortiz Polyclinic. Manzanillo. 2016-2017 / Prevalência e fatores de risco para obesidade em adolescentes René Vallejo Ortiz Polyclinic. Manzanillo. 2016-2017

RESUMEN La obesidad en adolescentes de Manzanillo constituye un problema de salud incipiente y complejo sin suficiente percepción del mismo. Con el objetivo de determinar los aspectos clínico - epidemiológicos asociados a la obesidad en los adolescentes del consultorio No. 602, del policlínico René Vallejo Ortiz, de Manzanillo, en el período comprendido desde enero de 2016 a enero de 2017, se realizó un estudio transversal o de prevalencia de adolescentes en edades comprendidas entre 11 a 19 años. El procesamiento y análisis de datos se realizó a partir de la información suministrada en la base de datos creada con el programa Microsoft Office Excel, lo cual se realizó mediante el estudio resumido de las frecuencias absolutas y relativas. En el análisis de asociación entre variables cualitativas se empleó la prueba no paramétrica de independencia Chi cuadrado de Pearson y la prueba de razón de posibilidades. Los factores de riesgos que condicionan la obesidad incluyen haber sido macrofeto durante el embarazo (OR = 5,95), antecedente de obesidad en la familia (OR = 3,66), y antecedente de trastornos lipídicos en los progenitores (OR = 2,83). Para resolver el problema de la obesidad en adolescentes se requiriere de nuevas estrategias destinadas al control de la enfermedad, el mejoramiento del estado de salud de esta población y el ascenso de los indicadores sanitarios del área en cuestión.

ABSTRACT Obesity in adolescents in Manzanillo constitutes an incipient and complex health problem without sufficient perception of it. With the aim of determining the clinical-epidemiological aspects associated with obesity in adolescents at clinic No. 602, at the René Vallejo Ortiz polyclinic in Manzanillo, in the period from January 2016 to January 2017, a cross-sectional study was conducted or prevalence of adolescents aged between 11 to 19 years. Data processing and analysis was carried out from the information provided in the database created with the Microsoft Office Excel program, which was carried out by means of the summary study of absolute and relative frequencies. In the analysis of association between qualitative variables, Pearson's non-parametric test of independence and the odds ratio test were used. The risk factors that condition obesity include having been a macro-fetus during pregnancy (OR = 5.95), a history of obesity in the family (OR = 3.66), and a history of lipid disorders in the parents (OR = 2, 83). In order to solve the problem of obesity in adolescents, new strategies are required to control the disease, improve the health status of this population and increase the health indicators of the area in question.

RESUMO A obesidade em adolescentes em Manzanillo constitui um problema de saúde incipiente e complexo sem uma percepção suficiente dele. Com o objetivo de determinar os aspectos clínico-epidemiológicos associados à obesidade em adolescentes da clínica nº 602, na policlínica René Vallejo Ortiz em Manzanillo, no período de janeiro de 2016 a janeiro de 2017, foi realizado um estudo transversal ou prevalência de adolescentes com idade entre 11 e 19 anos. O processamento e análise dos dados foram realizados a partir das informações fornecidas no banco de dados criado com o programa Microsoft Office Excel, realizado por meio do estudo sumário das frequências absolutas e relativas. Na análise da associação entre variáveis ​​qualitativas, foram utilizados o teste não paramétrico de independência e o odds ratio. Os fatores de risco que condicionam a obesidade incluem ter sido um macro-feto durante a gravidez (OR = 5,95), histórico de obesidade na família (OR = 3,66) e histórico de distúrbios lipídicos nos pais (OR = 2, 83) Para solucionar o problema da obesidade em adolescentes, novas estratégias são necessárias para controlar a doença, melhorar o estado de saúde dessa população e aumentar os indicadores de saúde da área em questão.

Economic Impact of Dengue: Multicenter Study across Four Brazilian Regions.

BACKGROUND: Dengue is an increasing public health concern in Brazil. There is a need for an updated evaluation of the economic impact of dengue within the country. We undertook this multicenter study to evaluate the economic burden of dengue in Brazil. METHODS: We estimated the economic burden of dengue in Brazil for the years 2009 to 2013 and for the epidemic season of August 2012- September 2013. We conducted a multicenter cohort study across four endemic regions: Midwest, Goiania; Southeast, Belo Horizonte and Rio de Janeiro; Northeast: Teresina and Recife; and the North, Belem. Ambulatory or hospitalized cases with suspected or laboratory-confirmed dengue treated in both the private and public sectors were recruited. Interviews were scheduled for the convalescent period to ascertain characteristics of the dengue episode, date of first symptoms/signs and recovery, use of medical services, work/school absence, household spending (out-of-pocket expense) and income lost using a questionnaire developed for a previous cost study. We also extracted data from the patients' medical records for hospitalized cases. Overall costs per case and cumulative costs were calculated from the public payer and societal perspectives. National cost estimations took into account cases reported in the official notification system (SINAN) with adjustment for underreporting of cases. We applied a probabilistic sensitivity analysis using Monte Carlo simulations with 90% certainty levels (CL). RESULTS: We screened 2,223 cases, of which 2,035 (91.5%) symptomatic dengue cases were included in our study. The estimated cost for dengue for the epidemic season (2012-2013) in the societal perspective was US$ 468 million (90% CL: 349-590) or US$ 1,212 million (90% CL: 904-1,526) after adjusting for under-reporting. Considering the time series of dengue (2009-2013) the estimated cost of dengue varied from US$ 371 million (2009) to US$ 1,228 million (2013). CONCLUSIONS: The economic burden associated with dengue in Brazil is substantial with large variations in reported cases and consequently costs reflecting the dynamic of dengue transmission.

Nefrectomía laparoscópica versus nefrectomía abierta. Experiencia en la Fundación Valle del Lili / Comparison between laparoscopic and nephrectomy at a colombia hospital

Objetivo: Comparar los resultados clínicos entre nefrectomía laparoscópica versus nefrectomía abierta en un hospital de Colombia. Métodos: Diseño: Cohorte retrospectiva. Lugar: Servicio de urología, Fundación Valle del Lili. Se incluyeron todos los pacientes que fueron llevados a nefrectomía laparoscópica o abierta entre 1995-2005. Se recolecto la información demográfica y clínica del procedimiento, hasta el egreso hospitalario. Los datos se analizaron en STATA v.8.0Resultados: Se incluyeron 143 pacientes. De ellos, 54 fueron tratados laparoscópicamente (laparoscopia total en 40, mano-asistida en 14) y con nefrectomía abierta en 89. El total de riñones extraídos fue de 161; 64 de ellos por laparoscopia. Los pacientes llevados a laparoscopia fueron más jóvenes (36 y 22 vs 48,5 y 19 años, p<0,05), pero con mucha más morbilidad (insuficiencia renal crónica). Hubo cuatro conversiones en los pacientes llevados a laparoscopia, todas por dificultades técnicas: una por salida de material purulento abundante, una por tumor de gran tamaño, y dos por adherencias...

Enfermedad de Von Hansemann: Reporte de 5 casos y revisión de la literatura / The Von Hansemann disease: 5 cases report and literature revision

La enfermedad de Von Hansemann es más conocida como Malacoplaquia (MPL). Es una enfermedad granulomatosa crónica poco frecuente. Se piensa que es secundaria a una alteración en el sistema fagocitario humano y se caracteriza por la presencia de una o varias tumoraciones que pueden aparecer virtualmente en cualquier parte del organismo, conllevando a un diagnóstico erróneo de malignidad. El tracto urinario es el sistema principalmente comprometido. El estudio patológico de las lesiones muestra un tejido infiltrado por células inflamatorias (macrófagos e histiositos) con presencia de unclusiones intracitoplamáticas denominadas cuerpos de Michaelis-Gutman. Usualmente es una enfermedad benigna autolimitada y se asocia a infecciones urinarias a repetición, pero la mayoría de las veces responde de manera adecuada a un tratamiento prolongado con quinolonas. Reportamos cinco casos diagnosticados en nuestra institución durante un período de ocho años, en los cuales reportamos también su manejo. Se realiza además una revisión de la literatura actual