Availability, cost and affordability of essential medicines for chronic respiratory diseases in low-income and middle-income countries: a cross-sectional study.

Contemporary data on the availability, cost and affordability of essential medicines for chronic respiratory diseases (CRDs) across low-income and middle-income countries (LMICs) are missing, despite most people with CRDs living in LMICs. Cross-sectional data for seven CRD medicines in pharmacies, healthcare facilities and central medicine stores were collected from 60 LMICs in 2022-2023. Medicines for symptomatic relief were widely available and affordable, while preventative treatments varied widely in cost, were less available and largely unaffordable. There is an urgent need to address these issues if the Sustainable Development Goal 3 is to be achieved for people with asthma by 2030.

Preclinical efficacy studies in investigator brochures: Do they enable risk-benefit assessment?

Human protection policies require favorable risk-benefit judgments prior to launch of clinical trials. For phase I and II trials, evidence for such judgment often stems from preclinical efficacy studies (PCESs). We undertook a systematic investigation of application materials (investigator brochures [IBs]) presented for ethics review for phase I and II trials to assess the content and properties of PCESs contained in them. Using a sample of 109 IBs most recently approved at 3 institutional review boards based at German Medical Faculties between the years 2010-2016, we identified 708 unique PCESs. We then rated all identified PCESs for their reporting on study elements that help to address validity threats, whether they referenced published reports, and the direction of their results. Altogether, the 109 IBs reported on 708 PCESs. Less than 5% of all PCESs described elements essential for reducing validity threats such as randomization, sample size calculation, and blinded outcome assessment. For most PCESs (89%), no reference to a published report was provided. Only 6% of all PCESs reported an outcome demonstrating no effect. For the majority of IBs (82%), all PCESs were described as reporting positive findings. Our results show that most IBs for phase I/II studies did not allow evaluators to systematically appraise the strength of the supporting preclinical findings. The very rare reporting of PCESs that demonstrated no effect raises concerns about potential design or reporting biases. Poor PCES design and reporting thwart risk-benefit evaluation during ethical review of phase I/II studies.

Preweaning cost of bovine respiratory disease (BRD) and cost-benefit of implementation of preventative measures in calves on California dairies: The BRD 10K study.

Bovine respiratory disease (BRD) is a multifactorial disease that is estimated to affect 22% of preweaned dairy calves in the United States and is a leading cause of preweaning mortality in dairy calves. Overall cost of calfhood BRD is reflected in both the immediate cost of treating the disease as well as lifetime decrease in production and increased likelihood of affected cattle leaving the herd before their second calving. The goal of this paper was to develop an estimate of the cost of BRD based on longitudinal treatment data from a study of BRD with a cohort of 11,470 preweaned dairy calves in California. Additionally, a cost-benefit analysis was performed for 2 different preventative measures for BRD, an increase of 0.47 L of milk per day for all calves or vaccination of all dams with a modified live BRD vaccine, using differing assumptions about birth rate and number of calves raised per year. Average short-term cost of BRD per affected calf was $42.15, including the use of anti-inflammatory medications in the treatment protocols across all management conditions. The cost of treating BRD in calves appears to have increased in recent years and is greater than costs presented in previous studies. A cost-benefit analysis examined different herd scenarios for a range of cumulative incidences of BRD from 3 to 25%. Increasing milk fed was financially beneficial in all scenarios above a 3% cumulative incidence of BRD. Use of a modified live vaccine in dams during pregnancy, examining only its value as a form of BRD prevention in the calves raised on the farm, was financially beneficial only if the cumulative incidence of BRD exceeded 10 to 15% depending on the herd size and whether the dairy farm was raising any bull calves. The cost-benefit analysis, under the conditions studied, suggests that producers with high rates of BRD may benefit financially from implementing preventative measures, whereas these preventative measures may not be cost effective to implement on dairy farms with very low cumulative incidences of BRD. The long-term costs of calfhood BRD on lifetime productivity were not factored into these calculations, and the reduction in disease may be associated with additional cost savings and an improvement in calf welfare and herd life.

Secondhand smoke exposure, illness severity, and resource utilization in pediatric emergency department patients with respiratory illnesses.

OBJECTIVE: Hospital-based data reveal that children who have secondhand smoke exposure (SHSe) experience severe respiratory illnesses and greater resource utilization. Our objective was to assess the relationship between SHSe and illness severity/resource utilization among children presenting to the pediatric emergency department (PED) with three common respiratory conditions-asthma, bronchiolitis, and pneumonia. METHODS: A retrospective review of a yearlong consecutive sample of PED patients with SHSe status documentation and asthma, bronchiolitis, or pneumonia diagnoses was performed. PED illness severity/resource utilization variables included triage categorization, initial oxygen saturation, evaluation/testing (influenza A & B, respiratory syncytial virus, chest X-ray), procedures/interventions performed (supplemental oxygen, suctioning, intubation), medications administered, and disposition. Logistic and linear regression models were conducted to determine differences in each diagnosis group while controlling for sociodemographics, medical history, seasonality, and insurance type. RESULTS: There were 3,229 children with documentation of SHSe status and an asthma (41%), bronchiolitis (36%), or pneumonia (23%) diagnosis. Across diagnosis groups, approximately 1/4 had positive documentation of SHSe. Asthmatic children with SHSe were more likely to receive corticosteroids (odds ratio (OR) = 1.71, 95% confidence interval (CI) = 1.19, 2.44) and/or magnesium sulfate (OR = 1.66, 95% CI = 1.14, 2.40). Children with SHSe and bronchiolitis were more likely to receive racemic epinephrine (OR = 2.48, 95% CI = 1.21, 5.08), have a chest X-ray (OR = 1.36, 95% CI = 1.00, 1.85), and/or be admitted (OR = 1.46, 95% CI = 1.09, 1.95). No differences in illness severity/resource utilization were identified for children with pneumonia. CONCLUSIONS: SHS-exposed children with asthma or bronchiolitis have greater illness severity/resource utilization. Our findings highlight the importance of SHSe assessment, cessation, and research efforts in the PED setting.

Use of programme budgeting and marginal analysis as a framework for resource reallocation in respiratory care in North Wales, UK.

BACKGROUND: Since the global financial crisis, UK NHS spending has reduced considerably. Respiratory care is a large cost driver for Betsi Cadwaladr University Health Board, the largest health board in Wales. Under the remit of 'prudent healthcare' championed by the Welsh Health Minister, a Programme Budgeting Marginal Analysis (PBMA) of the North Wales respiratory care pathway was conducted. METHODS: A PBMA panel of directors of medicines management, therapies finance, planning, public health and healthcare professionals used electronic voting to establish criteria for decision-making and vote on candidate interventions in which to disinvest and invest. RESULTS: A sum of £86.9 million was spent on respiratory care in 2012-13. Following extensive discussion of 13 proposed candidate interventions facilitated by a chairperson, 4 candidates received recommendations to disinvest, 7 to invest and 2 to maintain current activity. Marginal analysis prioritized mucolytics and high antibiotic prescribing as areas for disinvestment, and medicines waste management and pulmonary rehabilitation for investment. CONCLUSIONS: This exercise demonstrates the potential for health boards to use evidence-based approaches to reach potentially controversial disinvestment and investment decisions. Initial progress has begun with communication from the Medical Director in relation to the disinvestment in mucolytics prescribing and possible redirection of funding options being explored.

Survey and Chart Review to Estimate Medicare Cost Savings for Home Health as an Alternative to Hospital Admission Following Emergency Department Treatment.

BACKGROUND: Almost 70% of hospital admissions for Medicare beneficiaries originate in the emergency department (ED). Research suggests that some of these patients' needs may be better met through home-based care options after evaluation and treatment in the ED. OBJECTIVE: We sought to estimate Medicare cost savings resulting from using the Home Health benefit to provide treatment, when appropriate, as an alternative to inpatient admission from the ED. METHODS: This is a prospective study of patients admitted from the ED. A survey tool was used to query both emergency physicians (EPs) and patient medical record data to identify potential candidates and treatments for home-based care alternatives. Patient preferences were also surveyed. Cost savings were estimated by developing a model of Medicare Home Health to serve as a counterpart to the actual hospital-based care. RESULTS: EPs identified 40% of the admitted patients included in the study as candidates for home-based care. The top three major diagnostic categories included diseases and disorders of the respiratory system, digestive system, and skin. Services included intravenous hydration, intravenous antibiotics, and laboratory testing. The average estimated cost savings between the Medicare inpatient reimbursement and the Home Health counterpart was approximately $4000. Of the candidate patients surveyed, 79% indicated a preference for home-based care after treatment in the ED. CONCLUSIONS: Some Medicare beneficiaries could be referred to Home Health from the ED with a concomitant reduction in Medicare expenditures. Additional studies are needed to compare outcomes, develop the logistical pathways, and analyze infrastructure costs and incentives to enable Medicare Home Health options from the ED.

Low-Income Children, Adolescents, and Caregivers Facing Respiratory Problems: Support Needs and Preferences.

UNLABELLED: Burdens of poverty are often compounded by respiratory problems. This study aimed to identify the support needs and intervention preferences for low-income families facing this challenge. DESIGN AND METHODS: Interviews were conducted in two Canadian provinces with low-income children/adolescents (n=32) diagnosed with respiratory health problems and their parents or family caregiver (n=37). RESULTS: These vulnerable children and parents described non-supportive interactions with some health service providers and inadequate information. They reported isolation and support deficits, exacerbated by limited resources and health restrictions. Children/adolescents felt isolated and excluded and wanted to connect with peers. Group or dyadic level support, delivered by peers and health professionals, was desired. The importance of logistics to enhance accessibility and appeal of group or dyadic support interventions was clearly identified. CONCLUSIONS: The findings of this study reveal that low-income children and their families encounter challenges to accessing support and to utilizing support resources. PRACTICE IMPLICATIONS: Partnerships with low-income children/adolescents and family caregivers in provision of education and social support can combat isolation and ignorance. Reducing inequities for this high risk population could be achieved by providing support from experienced peers, in combination with health professional guidance, and knowledge about pulmonary health.

Excess costs and length of hospital stay attributable to perioperative respiratory events in children.

BACKGROUND: Knowledge of the excess hospital costs and prolonged length of stay attributable to perioperative respiratory event (PRE) in pediatric anesthesia is useful for hospital planning. In this study, we compared costs (excess hospital costs and indirect costs) and length of hospital stay between children who had PRE and did not have PRE for noncardiac surgery at a tertiary care hospital in southern Thailand. METHODS: A prospective matched cohort study was conducted in children aged <15 years who underwent general anesthesia between November 2012 and December 2013 at Songklanagarind Hospital. PRE children were matched with no PRE children (1:1) using a random selection procedure on outpatients/inpatients, type of surgery, surgical charge (baht), ASA physical status, age difference <9 years, and difference in time of surgery <6 months. Primary end points were excess hospital costs and number of days hospitalized after surgery. Number of days hospitalized after surgery, excess hospital costs and indirect costs regarding transportation, and income loss of parents between groups were compared using Wilcoxon signed rank test. Any hospital stay after surgery between groups was compared using McNemar χ test. A hurdle model was used to predict any hospital stay and number of days hospitalized after surgery. Multiple mixed-effects linear regression was used to identify predictors of adjusted excess hospital costs and indirect costs. RESULTS: A total 430 children were included (215 matched pairs). More PRE children required hospital stay after surgery (81% vs 72%, P = 0.004), and PRE children had a longer number of days hospitalized after surgery (median [interquartile ranges]: 1 [1-3.5] vs 1 [0-2]; P < 0.001) and incurred higher excess costs (P < 0.001) but not indirect costs (P = 0.23). In multivariate analysis, PRE was a significant predictor for hospital stay after surgery (odds ratio, 2.56; 95% confidence interval, 1.23-5.31), longer hospitalization (count ratio, 2.10 [1.31-3.35]), higher excess costs (cost ratio, 1.30 [1.12-1.53]), and indirect cost (cost ratio, 1.58 [1.20-2.08]) after adjusting for patient and anesthesia characteristics. Universal coverage (74%) was associated with 35% and 64% higher excess cost compared with the Comptroller General's Department (17%) and self-pay (7%), respectively (P = 0.003). CONCLUSIONS: The effects of PRE in pediatric anesthesia were hospital stay after surgery, 2 times longer hospitalization, 30% higher excess hospital costs, and 58% higher indirect cost among outpatients. Hospital policy to efficiently manage hospital beds and compensatory budget should be developed.

Delayed access to treatments for rare diseases: who's to blame?

The development and commercialization of drugs for rare diseases, termed 'orphan drugs', has historically been economically unattractive. However, because of the introduction of legislation that provides financial and regulatory incentives for the development of orphan drugs, new developments are making their way through the regulatory approval processes. Unfortunately, delays in availability of new drugs for treating rare disease continue to persist. This paper reviews the approach of several regulatory jurisdictions to orphan drugs in an effort to determine their relative effectiveness in providing patient access. Generally speaking, regulatory authorities across jurisdictions have recognized the need to enhance timely access to safe, effective treatment for patients with rare diseases and have been able to shift the approval timelines for access to new care. The greater impediment to orphan drug access appears to be funding, particularly in publicly sponsored health-care systems. Redundancies in federal and provincial reviews of orphan drugs can result in significant delays in access to new drugs. Clearly, more must be done to accelerate access to the treatments so desperately needed by patients. Public payers must be held accountable for their process and decisions--especially for rare disease therapies.

Climate change. A global threat to cardiopulmonary health.

Recent changes in the global climate system have resulted in excess mortality and morbidity, particularly among susceptible individuals with preexisting cardiopulmonary disease. These weather patterns are projected to continue and intensify as a result of rising CO2 levels, according to the most recent projections by climate scientists. In this Pulmonary Perspective, motivated by the American Thoracic Society Committees on Environmental Health Policy and International Health, we review the global human health consequences of projected changes in climate for which there is a high level of confidence and scientific evidence of health effects, with a focus on cardiopulmonary health. We discuss how many of the climate-related health effects will disproportionally affect people from economically disadvantaged parts of the world, who contribute relatively little to CO2 emissions. Last, we discuss the financial implications of climate change solutions from a public health perspective and argue for a harmonized approach to clean air and climate change policies.

The respiratory health of urban indigenous children aged less than 5 years: study protocol for a prospective cohort study.

BACKGROUND: Despite the burden of acute respiratory illnesses (ARI) among Aboriginal and Torres Strait Islander children being a substantial cause of childhood morbidity and associated costs to families, communities and the health system, data on disease burden in urban children are lacking. Consequently evidence-based decision-making, data management guidelines, health resourcing for primary health care services and prevention strategies are lacking. This study aims to comprehensively describe the epidemiology, impact and outcomes of ARI in urban Aboriginal and Torres Strait Islander children (hereafter referred to as Indigenous) in the greater Brisbane area. METHODS/DESIGN: An ongoing prospective cohort study of Indigenous children aged less than five years registered with a primary health care service in Northern Brisbane, Queensland, Australia. Children are recruited at time of presentation to the service for any reason. Demographic, epidemiological, risk factor, microbiological, economic and clinical data are collected at enrolment. Enrolled children are followed for 12 months during which time ARI events, changes in child characteristics over time and monthly nasal swabs are collected. Children who develop an ARI with cough as a symptom during the study period are more intensely followed-up for 28 (±3) days including weekly nasal swabs and parent completed cough diary cards. Children with persistent cough at day 28 post-ARI are reviewed by a paediatrician. DISCUSSION: Our study will be one of the first to comprehensively evaluate the natural history, epidemiology, aetiology, economic impact and outcomes of ARIs in this population. The results will inform studies for the development of evidence-based guidelines to improve the early detection, prevention and management of chronic cough and setting of priorities in children during and after ARI. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry Registration Number: 12614001214628 . Registered 18 November 2014.

The geographic distribution and economic value of climate change-related ozone health impacts in the United States in 2030.

UNLABELLED: In this United States-focused analysis we use outputs from two general circulation models (GCMs) driven by different greenhouse gas forcing scenarios as inputs to regional climate and chemical transport models to investigate potential changes in near-term U.S. air quality due to climate change. We conduct multiyear simulations to account for interannual variability and characterize the near-term influence of a changing climate on tropospheric ozone-related health impacts near the year 2030, which is a policy-relevant time frame that is subject to fewer uncertainties than other approaches employed in the literature. We adopt a 2030 emissions inventory that accounts for fully implementing anthropogenic emissions controls required by federal, state, and/or local policies, which is projected to strongly influence future ozone levels. We quantify a comprehensive suite of ozone-related mortality and morbidity impacts including emergency department visits, hospital admissions, acute respiratory symptoms, and lost school days, and estimate the economic value of these impacts. Both GCMs project average daily maximum temperature to increase by 1-4°C and 1-5 ppb increases in daily 8-hr maximum ozone at 2030, though each climate scenario produces ozone levels that vary greatly over space and time. We estimate tens to thousands of additional ozone-related premature deaths and illnesses per year for these two scenarios and calculate an economic burden of these health outcomes of hundreds of millions to tens of billions of U.S. dollars (2010$). IMPLICATIONS: Near-term changes to the climate have the potential to greatly affect ground-level ozone. Using a 2030 emission inventory with regional climate fields downscaled from two general circulation models, we project mean temperature increases of 1 to 4°C and climate-driven mean daily 8-hr maximum ozone increases of 1-5 ppb, though each climate scenario produces ozone levels that vary significantly over space and time. These increased ozone levels are estimated to result in tens to thousands of ozone-related premature deaths and illnesses per year and an economic burden of hundreds of millions to tens of billions of U.S. dollars (2010$).

Burden of Sickness Absence Due to Chronic Disease in the Dutch Workforce from 2007 to 2011.

INTRODUCTION: Chronic diseases are associated with productivity loss costs due to sickness absence. It is not always clear, however, which chronic diseases in particular are involved with how many sickness days and associated costs. OBJECTIVE: To determine the prevalence, additional days of sickness absence, and associated costs of chronic diseases among the Dutch working population from 2007 to 2011. METHODS: Prevalence of chronic diseases and additional days of sickness absence were derived from the Netherlands Working Conditions Survey (NWCS) from 2007 to 2011. The cost of each sickness absence day was based on linked personal income data. We used multiple regression analysis to derive the unconfounded additional days of sickness absence due to each chronic disease. RESULTS: Annually, approximately 37 % of the Dutch working population reported some type of chronic physical or psychological disease. No clinically relevant changes in prevalence of specific chronic diseases were observed in the studied period, nor in the number of additional sickness absence days or associated costs. The national financial burden due to sickness absence associated with chronic musculoskeletal disorders amounted to €1.3 billion annually. CONCLUSIONS: Chronic diseases result in substantial productivity loss due to sickness absence. Given the ageing population, the proposed increase in the state pension age and an increase in sedentary lifestyle and obesity, the prevalence of chronic diseases may be expected to rise. Coordinated efforts to maintain and improve the health of the working population are necessary to minimize socioeconomic consequences.

Burden of total and cause-specific mortality related to tobacco smoking among adults aged ≥ 45 years in Asia: a pooled analysis of 21 cohorts.

BACKGROUND: Tobacco smoking is a major risk factor for many diseases. We sought to quantify the burden of tobacco-smoking-related deaths in Asia, in parts of which men's smoking prevalence is among the world's highest. METHODS AND FINDINGS: We performed pooled analyses of data from 1,049,929 participants in 21 cohorts in Asia to quantify the risks of total and cause-specific mortality associated with tobacco smoking using adjusted hazard ratios and their 95% confidence intervals. We then estimated smoking-related deaths among adults aged ≥45 y in 2004 in Bangladesh, India, mainland China, Japan, Republic of Korea, Singapore, and Taiwan-accounting for ∼71% of Asia's total population. An approximately 1.44-fold (95% CI = 1.37-1.51) and 1.48-fold (1.38-1.58) elevated risk of death from any cause was found in male and female ever-smokers, respectively. In 2004, active tobacco smoking accounted for approximately 15.8% (95% CI = 14.3%-17.2%) and 3.3% (2.6%-4.0%) of deaths, respectively, in men and women aged ≥45 y in the seven countries/regions combined, with a total number of estimated deaths of ∼1,575,500 (95% CI = 1,398,000-1,744,700). Among men, approximately 11.4%, 30.5%, and 19.8% of deaths due to cardiovascular diseases, cancer, and respiratory diseases, respectively, were attributable to tobacco smoking. Corresponding proportions for East Asian women were 3.7%, 4.6%, and 1.7%, respectively. The strongest association with tobacco smoking was found for lung cancer: a 3- to 4-fold elevated risk, accounting for 60.5% and 16.7% of lung cancer deaths, respectively, in Asian men and East Asian women aged ≥45 y. CONCLUSIONS: Tobacco smoking is associated with a substantially elevated risk of mortality, accounting for approximately 2 million deaths in adults aged ≥45 y throughout Asia in 2004. It is likely that smoking-related deaths in Asia will continue to rise over the next few decades if no effective smoking control programs are implemented. Please see later in the article for the Editors' Summary.

Forecast-based interventions can reduce the health and economic burden of wildfires.

We simulated public health forecast-based interventions during a wildfire smoke episode in rural North Carolina to show the potential for use of modeled smoke forecasts toward reducing the health burden and showed a significant economic benefit of reducing exposures. Daily and county wide intervention advisories were designed to occur when fine particulate matter (PM2.5) from smoke, forecasted 24 or 48 h in advance, was expected to exceed a predetermined threshold. Three different thresholds were considered in simulations, each with three different levels of adherence to the advisories. Interventions were simulated in the adult population susceptible to health exacerbations related to the chronic conditions of asthma and congestive heart failure. Associations between Emergency Department (ED) visits for these conditions and daily PM2.5 concentrations under each intervention were evaluated. Triggering interventions at lower PM2.5 thresholds (≤ 20 µg/m(3)) with good compliance yielded the greatest risk reduction. At the highest threshold levels (50 µg/m(3)) interventions were ineffective in reducing health risks at any level of compliance. The economic benefit of effective interventions exceeded $1 M in excess ED visits for asthma and heart failure, $2 M in loss of productivity, $100 K in respiratory conditions in children, and $42 million due to excess mortality.

State and national household concentrations of PM2.5 from solid cookfuel use: results from measurements and modeling in India for estimation of the global burden of disease.

BACKGROUND: Previous global burden of disease (GBD) estimates for household air pollution (HAP) from solid cookfuel use were based on categorical indicators of exposure. Recent progress in GBD methodologies that use integrated-exposure-response (IER) curves for combustion particles required the development of models to quantitatively estimate average HAP levels experienced by large populations. Such models can also serve to inform public health intervention efforts. Thus, we developed a model to estimate national household concentrations of PM2.5 from solid cookfuel use in India, together with estimates for 29 states. METHODS: We monitored 24-hr household concentrations of PM2.5, in 617 rural households from 4 states in India on a cross-sectional basis between November 2004 and March 2005. We then, developed log-linear regression models that predict household concentrations as a function of multiple, independent household level variables available in national household surveys and generated national / state estimates using The Indian National Family and Health Survey (NFHS 2005). RESULTS: The measured mean 24-hr concentration of PM2.5 in solid cookfuel using households ranged from 163 µg/m3 (95% CI: 143,183; median 106; IQR: 191) in the living area to 609 µg/m3 (95% CI: 547,671; median: 472; IQR: 734) in the kitchen area. Fuel type, kitchen type, ventilation, geographical location and cooking duration were found to be significant predictors of PM2.5 concentrations in the household model. k-fold cross validation showed a fair degree of correlation (r = 0.56) between modeled and measured values. Extrapolation of the household results by state to all solid cookfuel-using households in India, covered by NFHS 2005, resulted in a modeled estimate of 450 µg/m3 (95% CI: 318,640) and 113 µg/m3 (95% CI: 102,127) , for national average 24-hr PM2.5 concentrations in the kitchen and living areas respectively. CONCLUSIONS: The model affords substantial improvement over commonly used exposure indicators such as "percent solid cookfuel use" in HAP disease burden assessments, by providing some of the first estimates of national average HAP levels experienced in India. Model estimates also add considerable strength of evidence for framing and implementation of intervention efforts at the state and national levels.

Using PM2.5 concentrations to estimate the health burden from solid fuel combustion, with application to Irish and Scottish homes.

BACKGROUND: This study estimates the potential population health burden from exposure to combustion-derived particulate air pollution in domestic settings in Ireland and Scotland. METHODS: The study focused on solid fuel combustion used for heating and the use of gas for cooking. PM2.5 (particulate matter with an aerodynamic diameter < 2.5 µm) was used as the pollutant mixture indicator. Measured PM2.5 concentrations in homes using solid fuels were adjusted for other sources of PM2.5 by subtracting PM2.5 concentrations in homes using gas for cooking but not solid fuel heating. Health burden was estimated for exposure indoors 6 pm - midnight, or all day (24-hour), by combining estimated attributable annual PM2.5 exposures with (i) selected epidemiological functions linking PM2.5 with mortality and morbidity (involving some re-scaling from PM10 to PM2.5, and adjustments 'translating' from concentrations to exposures) and (ii) on the current population exposed and background rates of morbidity and mortality. RESULTS: PM2.5 concentrations in coal and wood burning homes were similar to homes using gas for cooking, used here as a baseline (mean 24-hr PM2.5 concentrations 8.6 µg/m3) and so health impacts were not calculated. Concentrations of PM2.5 in homes using peat were higher (24-hr mean 15.6 µg/m3); however, health impacts were calculated for the exposed population in Ireland only; the proportion exposed in Scotland was very small. The assessment for winter evening exposure (estimated annual average increase of 2.11 µg/m3 over baseline) estimated 21 additional annual cases of all-cause mortality, 55 of chronic bronchitis, and 30,100 and 38,000 annual lower respiratory symptom days (including cough) and restricted activity days respectively. CONCLUSION: New methods for estimating the potential health burden of combustion-generated pollution from solid fuels in Irish and Scottish homes are provided. The methodology involves several approximations and uncertainties but is consistent with a wider movement towards quantifying risks in PM2.5 irrespective of source. Results show an effect of indoor smoke from using peat (but not wood or coal) for heating and cooking; but they do not suggest that this is a major public health issue.

Impact of respiratory disease, diarrhea, otitis and arthritis on mortality and carcass traits in white veal calves.

BACKGROUND: Little is known on the effects of common calf diseases on mortality and carcass traits in the white veal industry (special-fed veal), a highly integrated production system, currently criticized for the intensive pro- and metaphylactic use of antimicrobials. The objective of the present study was to determine the impact of bovine respiratory disease (BRD), diarrhea, arthritis and otitis on the economically important parameters of mortality, hot carcass weight (HCW), carcass quality, fat cover and meat color. For this purpose, a prospective study on 3519 white veal calves, housed in 10 commercial herds, was conducted. Case definitions were based on clinical observation by the producers and written treatment records were used. RESULTS: Calves received oral antimicrobial group treatments in the milk during 25.2% of the production time on average. With an increasing percentage of the production cycle spent on oral antimicrobials, HCW reduced, whereas the odds for insufficient fat cover or an undesirable red meat color both decreased. Of the calves, 14.8%, 5.3%, 1.5% and 1.6% were individually diagnosed and treated for BRD, diarrhea, arthritis and otitis, respectively. Overall, 5.7% of the calves died and the mortality risk was higher in the first weeks after arrival. Calves that experienced one BRD episode showed a 8.2 kg reduction in HCW, a lower fat cover and an increased mortality risk (hazard ratio (HR) = 5.5), compared to calves which were not individually diagnosed and treated for BRD. With an increasing number of BRD episodes, these losses increased dramatically. Additionally, calves, which experienced multiple BRD episodes, were more likely to have poor carcass quality and an undesirable red meat color at slaughter. Arthritis increased the mortality risk (HR = 3.9), and reduced HCW only when associated with BRD. Otitis did only increase the mortality risk (HR = 7.0). Diarrhea severely increased the mortality risk (HR = 11.0), reduced HCW by 9.2 kg on average and decreased carcass quality. CONCLUSIONS: Despite the massive use of group and individual treatments to alleviate the most prevalent health issues at the fattening period, the effects of BRD, diarrhea, otitis and arthritis on survival and performance are still considerable, especially in cases of chronic pneumonia with or without arthritis. Controlling calf health by effective preventive and therapeutic strategies and in particular the prevention of chronic BRD is key for the profitability of veal operations.

Respiratory diseases: meeting the challenges of screening, prevention, and treatment.

Respiratory conditions, both acute and chronic, continue to have a significant impact on worldwide health because of their high prevalence, the high disease burden they place on individual health, and their enormous cost to the health care system. There are also unmeasured indirect economic costs due to loss of productivity. Despite advances in our understanding of the complex pathophysiology of respiratory diseases, as well as the availability of relatively straightforward primary prevention measures, the prevalence of chronic respiratory diseases continues to rise. In addition, periodic outbreaks of acute infectious respiratory conditions result in significant cost and even mortality, and the incidence of these conditions fluctuates widely from year to year. Although we have seen recent developments in medical therapies for respiratory diseases, and there are established and well-publicized disease management guidelines, morbidity and mortality remain high. One intervention that has lagged behind has been smoking prevention and cessation, which is the mainstay of prevention for chronic obstructive pulmonary disease and lung cancer. The persistence of these conditions underscores vulnerabilities within our national and regional health care systems. Several of the articles in this issue of the NCMJ describe innovative programs to address these challenges.

RSV hospitalisation and healthcare utilisation in moderately prematurely born infants.

Respiratory syncytial virus (RSV) infection is associated with chronic respiratory morbidity in infants born very prematurely. Our aims were to determine if infants born moderately prematurely (32--35 weeks of gestation) who had had an RSV hospitalisation, compared to those who had not, had greater healthcare utilisation and related cost of care in the first 2 years. Two thousand and sixty-six eligible infants' records were examined to identify three groups: 20 infants admitted for an RSV lower respiratory tract infection (RSV), 30 admitted for another respiratory problem (other respiratory) and 108 admitted for a nonrespiratory problem/never admitted (non-respiratory).Healthcare utilisation was assessed by examining hospital and general practitioner records and cost of care calculated using the National Scheme of Reference costs and the British National Formulary prices. The mean cost of care in the RSV group (£12,505) was greater than the non-respiratory(£1,178) (95% CI for difference £5,015 to £17,639, p=00.002) and the other respiratory (£3,356) groups (95% CI for difference £2,963 to £15,606, p<0.001). The adjusted mean differences in the cost of care were £11,186 between the RSV and non-respiratory groups (95% CI £4,763 to £17,609) and £9,076 (95% CI £2,515 to £15,637) between the RSV and the other respiratory groups. Forty-two of 2,066 eligible infants had an RSV hospitalisation (2%);thus, assuming prophylaxis would reduce the hospitalisation rate by 50%, the number needed to treat was 98. In conclusion,RSV hospitalisation in moderately prematurely born infants is associated with increased health-related cost of care. Nevertheless, if RSV prophylaxis is to be cost effective,a high risk group of moderately prematurely born infants needs to be identified.