Selectively recommend 18F-FDG PET/CT for patients with de novo nasopharyngeal carcinoma in endemic areas.

INTRODUCTION: To identify the subset of patients with de novo nasopharyngeal carcinoma (NPC) for whom [18F] fluorodeoxyglucose positron emission tomography and computed tomography (18F-FDG PET/CT) should be recommended, and to determine whether PET/CT is a cost-effective decision for precise M staging in endemic areas. MATERIALS AND METHODS: Retrospective analysis of data of 4469 patients diagnosed with de novo NPC between January 2014 and December 2019. The detection rate of distant metastasis was compared between different groups. Univariate and multiple logistic regression analysis was applied to identify the risk factors for distant metastasis. The cost-effectiveness of the diagnostic strategies was assessed. RESULTS: The detection rate of distant metastasis in the whole cohort was 5.46%. In multivariate analysis, male sex, T3-4 stage, N2-3 stage, and high plasma Epstein-Barr virus (EBV) DNA (≥ 14,650 copies/mL) were risk factors for distant metastases. NPC patients with T3-4 stage combined with N2-3 stage, high EBV DNA combined with male sex, or N2-3 stage combined with high EBV DNA were defined as recommended group with relatively higher tendency for metastasis. Distant metastasis incidence in recommended group and unrecommended group were 10.25% and 1.75%, respectively (P < 0.001). In the recommended group, PET/CT significantly improved the detection rate of distant metastasis (13.25% vs 9.02%, P = 0.005). Cost-effectiveness analysis revealed that additional cost for every one percent increase in distant metastasis detection rate was $22,785.58 in the recommended group (< Willingness-to-pay (WTP) threshold of $32,700.00) and $310,912.90 in the unrecommended group. CONCLUSIONS: In patients with de novo NPC, the tendency for metastasis can be predicted based on clinical parameters. 18F-FDG PET/CT should be selectively recommended for the subset of patients with a relatively higher tendency for metastasis.

A Model of Care Optimized for Marginalized Remote Population Unravels Migration Pattern in India.

BACKGROUND AND AIMS: Access to basic health needs remains a challenge for most of world's population. In this study, we developed a care model for preventive and disease-specific health care for an extremely remote and marginalized population in Arunachal Pradesh, the northeasternmost state of India. APPROACH AND RESULTS: We performed patient screenings, performed interviews, and obtained blood samples in remote villages of Arunachal Pradesh through a tablet-based data collection application, which was later synced to a cloud database for storage. Positive cases of hepatitis B virus (HBV) were confirmed and genotyped in our central laboratory. The blood tests performed included liver function tests, HBV serologies, and HBV genotyping. HBV vaccination was provided as appropriate. A total of 11,818 participants were interviewed, 11,572 samples collected, and 5,176 participants vaccinated from the 5 westernmost districts in Arunachal Pradesh. The overall hepatitis B surface antigen (HBsAg) prevalence was found to be 3.6% (n = 419). In total, 34.6% were hepatitis B e antigen positive (n = 145) and 25.5% had HBV DNA levels greater than 20,000 IU/mL (n = 107). Genotypic analysis showed that many patients were infected with HBV C/D recombinants. Certain tribes showed high seroprevalence, with rates of 9.8% and 6.3% in the Miji and Nishi tribes, respectively. The prevalence of HBsAg in individuals who reported medical injections was 3.5%, lower than the overall prevalence of HBV. CONCLUSIONS: Our unique, simplistic model of care was able to link a highly resource-limited population to screening, preventive vaccination, follow-up therapeutic care, and molecular epidemiology to define the migratory nature of the population and disease using an electronic platform. This model of care can be applied to other similar settings globally.

Addressing budget reduction and reallocation on health-related resources during COVID-19 pandemic in malaria-endemic countries.

The global COVID-19 pandemic has been affecting the maintenance of various disease control programmes, including malaria. In some malaria-endemic countries, funding and personnel reallocations were executed from malaria control programmes to support COVID-19 response efforts, resulting mainly in interruptions of disease control activities and reduced capabilities of health system. While it is principal to drive national budget rearrangements during the pandemic, the long-standing malaria control programmes should not be left behind in order to sustain the achievements from the previous years. With different levels of intensity, many countries have been struggling to improve the health system resilience and to mitigate the unavoidable stagnation of malaria control programmes. Current opinion emphasized the impacts of budget reprioritization on malaria-related resources during COVID-19 pandemic in malaria endemic countries in Africa and Southeast Asia, and feasible attempts that can be taken to lessen these impacts.

Polio in Afghanistan: The Current Situation amid COVID-19.

Polio is a deadly viral disease that has been paralyzing many children in Afghanistan. Despite fundamental efforts, primarily vaccination, to reduce the number of cases in Afghanistan, there are still many children who are deprived of the vaccine every year. Afghanistan is one of the two remaining countries endemic for polio, and the country has undergone various challenges that have hampered the eradication of this disease. The underlying challenges include inaccessibility of unsecured areas, illiteracy, refusal, and, most recently, COVID-19. The country is in the midst of a battle against COVID-19, and polio has almost entirely been neglected. Sadly, polio cases are increasing in the country, particularly in polio-free provinces. After an initial lockdown, many businesses have been allowed to resume, but the mass polio vaccination campaign has not restarted. New cases of polio will surge if endemic regions remain unvaccinated or inaccessible. To curb the further spread of polio, Afghanistan needs to resume nationwide house-to-house vaccination as restrictions due to COVID-19 are loosened.

The cost of a school based mass treatment of schistosomiasis in Ugu District, KwaZulu Natal, South Africa in 2012.

INTRODUCTION: The Neglected Tropical Diseases Roadmap of the WHO set targets for potential elimination as a "public health problem" for the period 2012-2020 in multiple countries in Africa, with the aim of global elimination of schistosomiasis as a "public health problem" by 2025. AIM: The purpose of the study was to estimate the cost from a provider's perspective of the Department of Health's Schistosomiasis Mass Drug Administration (MDA) in Ugu District, KwaZulu-Natal in 2012, with a view to project the costs for the entire KwaZulu Natal Province. METHODS: A total of 491 public schools and 16 independent schools in Ugu District, a predominantly rural district in KwaZulu-Natal with a total of 218 242 learners, were included in the schistosomiasis control programme. They were randomly selected from schools situated below an altitude of 300 meters, where schistosomiasis is endemic. A retrospective costing study was conducted using the provider's perspective to cost. Cost data were collected by reviewing existing records including financial statements, invoices, receipts, transport log books, equipment inventories, and information from personnel payroll, existing budget, and the staff diaries. RESULTS: A total of 15571 children were treated in 2012, resulting in a total cost of the MDA programme of ZAR 2 137 143 and a unit cost of ZAR 137. The three main cost components were Medication Costs (37%), Human Resources Cost (36%) and Capital items (16%). The total cost for treating all eligible pupils in KwaZulu-Natal will be ZAR 149 031 888. However, should the capital cost be excluded, then the unit cost will be ZAR 112 per patient and this will translate to a total cost of ZAR 121 836 288. CONCLUSIONS: Low coverage exacerbates the cost of the programme and makes a decision to support such a programme difficult. However, a normative costing study based on the integration of the programme within the Department of Health should be conducted.

Epidemiological Investigation of Toxoplasma gondii Infections in Commercial Sheep Flock in an Endemic Area for Ocular Toxoplasmosis in Southern Brazil.

INTRODUCTION: Toxoplasma gondii is a widely distributed parasite and of great importance to human and animal health. METHODS: The objective of this study was to assess the prevalence of T. gondii antibodies and risk factors associated with the infection in sheep in the Northwest region of the State of Rio Grande do Sul, Brazil; this region has a very high rate of human ocular toxoplasmosis. Ovine sera were tested by the modified agglutination test (cut-off 1:25). RESULTS: T. gondii antibodies were detected in 70.2% (224 of 319). According to the logistic regression, the most significant factors associated were age and cat access to food stock facility. CONCLUSION: Preventive measures are discussed to reduce the risk of transmission of this zoonosis.

Problems with the WHO TB model.

WHO tuberculosis researchers recently published a mathematical model to predict TB incidence decline with fulfillment of Sustainable Development Goal (SDG) subtargets [1]. This model omitted the subtargets of land rights and basic services and of reduction in deaths from climatic disaster, likely highly influential factors, and retained only social insurance and reduction of extreme poverty as independent variables. The model predicted that fulfillment of these two subtargets will result in very large declines in TB incidence. This paper critiques the WHO model, reviews historic documents in TB social epidemiology, and examines dynamics of institutional effectiveness and efficiency in endemic disease control under conditions of systemic uncertainty associated with imbalances in population-level power relations, leading to exploding variance. These documents, and our own modeling exercise, indicate that the WHO model omits important determinations of TB incidence: war, civil conflict, and major upheaval such as rural and urban mass evictions; gross imbalance of power; accumulation of wealth into the hands of a tiny part of the global population; unequal female/male literacy and general low literacy level. Simple models should not be used for public policy, especially not-yet-validated models. The WHO model substitutes money for anti-TB medicines and leaves the underlying long-term causes of high TB incidence intact. Short-term reductions in TB incidence may be followed by increases as intervention effectiveness and efficiency ebb.

Patients' costs, socio-economic and health system aspects associated with malaria in pregnancy in an endemic area of Colombia.

Malaria in pregnancy threatens birth outcomes and the health of women and their newborns. This is also the case in low transmission areas, such as Colombia, where Plasmodium vivax is the dominant parasite species. Within the Colombian health system, which underwent major reforms in the 90s, malaria treatment is provided free of charge to patients. However, patients still incur costs, such as transportation and value of time lost due to the disease. We estimated such costs among 40 pregnant women with clinical malaria (30% Plasmodium falciparum, 70% Plasmodium vivax) in the municipality of Tierralta, Northern Colombia. In a cross-sectional study, women were interviewed after an outpatient or inpatient laboratory confirmed malaria episode. Women were asked to report all types of cost incurred before (including prevention), during and immediately after the contact with the health facility. Median total cost was over 16US$ for an outpatient visit, rising to nearly 30US$ if other treatments were sought before reaching the health facility. Median total inpatient cost was 26US$ or 54US$ depending on whether costs incurred prior to admission were excluded or included. For both outpatients and inpatients, direct costs were largely due to transportation and indirect costs constituted the largest share of total costs. Estimated costs are likely to represent only one of the constraints that women face when seeking treatment in an area characterized, at the time of the study, by armed conflict, displacement, and high vulnerability of indigenous women, the group at highest risk of malaria. Importantly, the Colombian peace process, which culminated with the cease-fire in August 2016, may have a positive impact on achieving universal access to healthcare in conflict areas. The current study can inform malaria elimination initiatives in Colombia.

Where to next with animal health in Latin America? The transition from endemic to disease-free status.

The Latin American and Caribbean region (LAC) is a leading global producer and exporter of animal products. Its livestock production systems are diverse, ranging from large-scale commercial enterprises to family farms. Countries in this region have sought to improve their animal health status through both public and private efforts. Despite significant advances in eradicating such diseases as foot and mouth disease and classical swine fever, other animal health challenges remain; constraining exports, causing negative economic impacts and threatening food security. Obtaining certification of disease-free status is only the first step towards gaining benefits from improvements in animal health. Increasing international trade means that countries must manage the sustainability of their disease-free status in conjunction with trade partners and must comply with additional food safety and animal welfare standards. This paper comments on the challenges created by this new scenario in relation to the epidemiology and economics of animal health, when seeking to improve decisionmaking for animal health management. The authors characterise the current LAC livestock landscape and animal health situation, describing transitions in disease control and the use of economics in improving animal health. They conclude with remarks on the challenges presented by decision-making, economic rationality, sources of benefits, distribution and incentives.

La région Amérique latine et Caraïbes est l'une des principales régions productrices et exportatrices de produits d'origine animale dans le monde. Les systèmes de production du secteur de l'élevage y sont très diversifiés, depuis les petites exploitations familiales jusqu'aux élevages commerciaux à grande échelle. Les pays de la région ont cherché à améliorer la situation de la santé animale sur leur territoire en y consacrant les efforts de leur secteur public et privé. Malgré les avancées considérables réalisées dans l'éradication de maladies comme la fièvre aphteuse et la peste porcine classique, la santé animale est encore confrontée à des problèmes qui freinent les exportations et ont un impact économique négatif, tout en menaçant la sécurité de l'approvisionnement alimentaire. La reconnaissance officielle du statut indemne de maladie ne représente qu'une première étape dans le processus visant à générer des bénéfices grâce à une meilleure santé animale. L'intensification des échanges internationaux impose aux pays de s'assurer de la durabilité de leur statut indemne aux côtés de leurs partenaires commerciaux et de respecter de nouvelles normes relatives à la sécurité sanitaire des aliments et au bien-être animal. Les auteurs analysent les conséquences de ce scénario sur l'épidémiologie et l'économie de la santé animale ainsi que ses enjeux dans la recherche d'une meilleure prise de décisions dans la gestion de la santé animale. Ils définissent ensuite le paysage actuel de l'élevage et la situation de la santé animale en Amérique latine et dans les Caraïbes et décrivent les évolutions à l'oeuvre en matière de lutte contre les maladies animales et d'utilisation de l'économie dans l'amélioration de la santé animale. Ils concluent sur quelques remarques concernant les difficultés qui se présentent en matière de prise de décision, de rationalité économique, de sources de profit, de distribution et d'incitation.

La región de América Latina y el Caribe es uno de los principales productores y exportadores de productos animales del mundo. Sus sistemas de producción ganadera exhiben gran heterogeneidad, pues van desde las grandes empresas de dimensión industrial hasta las pequeñas explotaciones familiares. Apoyándose en la iniciativa tanto pública como privada, los países de la región vienen tratando de mejorar su situación zoosanitaria. Pese a los importantes progresos registrados en la erradicación de enfermedades como la fiebre aftosa o la peste porcina clásica, subsisten otros problemas de sanidad animal que restringen las exportaciones, lastran la economía y amenazan la seguridad alimentaria. La certificación de «ausencia de enfermedad¼ es solo el primer paso para beneficiarse de las mejoras conseguidas en el terreno de la sanidad animal. Habida cuenta de la intensificación del comercio internacional, los países deben gestionar la continuidad a largo plazo de su estatuto de «libres de enfermedad¼ conjuntamente con sus socios comerciales y, para ello, cumplir normas adicionales en material de inocuidad de los alimentos y bienestar animal. Los autores exponen las dificultades que se plantean en esta nueva coyuntura de la epidemiología y la economía de la sanidad animal a la hora de mejorar los procesos decisorios en materia de gestión zoosanitaria. Tras caracterizar el actual paisaje de la ganadería y la situación zoosanitaria en América Latina y el Caribe, describen la transición que se está operando en cuanto al control de enfermedades y al uso de la economía para mejorar la sanidad animal y concluyen con una serie de observaciones sobre los problemas que surgen en relación con la adopción de decisiones, la racionalidad económica, las fuentes de beneficios y las cuestiones ligadas a la distribución y los incentivos.

Assessing the economic impact of an endemic disease: the case of mastitis.

A large part of the world's resources are used to produce animal products. Efficient use of these resources is important to improve social well-being. Endemic animal diseases decrease production efficiency, because they require a higher level of input to produce the same amount of output or result in a lower output with the same amount of input. The optimal level of production with and without disease differs from farm to farm and depends on varying economic circumstances. Given these difficulties, making an accurate theoretical estimation of the economic impact of endemic diseases is challenging. Current approaches towards the economic assessment of endemic diseases are, therefore, quite pragmatic. For on-farm decision-making, the total costs consist of failure costs and preventive costs. Failure costs are associated with production losses (i.e. decreases in milk production, mortality and culling), treatment costs (i.e. veterinary treatment, drugs, and discarded milk) and the use of other resources associated with the occurrence of disease (i.e. increased labour costs). Preventive costs are associated with preventive measures in terms of equipment, consumables (e.g. diagnostics and chemicals) and the use of other resources to prevent diseases (i.e. increased labour). There is a substitution relationship between failure costs and preventive costs. That means that, in order to maximise profit at the farm level, the amount of resources invested in prevention should be chosen in such a way that total costs are minimised. The most studied endemic disease in animal production is mastitis. Most publications on mastitis only assess failure costs, and studies on assessing the total costs and best methods to determine an optimal level of prevention are scarce. Future challenges lie in researching frameworks that can assist decision-makers to establish optimal prevention levels for endemic diseases.

Une grande partie des ressources mondiales est consacrée à la production de produits d'origine animale. Il est important d'utiliser rationnellement ces ressources si l'on veut améliorer le bien-être des sociétés. Les maladies animales endémiques réduisent la rentabilité des élevages car en cas de maladie il faut plus d'intrants pour maintenir le niveau de production, tandis que celui-ci décroît si la quantité d'intrants demeure inchangée. Le niveau optimal de production avec ou sans maladie varie d'une exploitation à l'autre et dépend du contexte et des fluctuations économiques. Ces facteurs complexes expliquent la difficulté de réaliser une estimation théorique exacte de l'impact économique des maladies endémiques. En conséquence, les approches actuelles en matière d'évaluation économique des maladies animales privilégient le pragmatisme. Au niveau décisionnel des élevages, les coûts totaux englobent les pertes d'exploitation et les coûts de la prévention. Les pertes d'exploitation sont liées aux pertes de production (baisse de la production de lait, mortalité et animaux sacrifiés), au coût des traitements (prestations vétérinaires, médicaments, perte de lait en raison des traitements) et à l'utilisation d'autres ressources en lien avec l'apparition de la maladie (augmentation des coûts de main-d'oeuvre). Les coûts de prévention sont liés aux mesures de prévention et couvrent les équipements, les consommables (les réactifs et matériels de diagnostic et les produits chimiques) et l'utilisation d'autres ressources pour prévenir les maladies (augmentation des coûts de maind'oeuvre). Les pertes d'exploitation et les coûts de prévention sont mutuellement substituables. Ainsi, pour optimiser la rentabilité à l'échelle de la ferme, il conviendra de choisir le montant des ressources investies dans la prévention de manière à minimiser les coûts totaux. La mammite est la maladie endémique la plus étudiée en production animale. La plupart des publications sur la mammite évaluent uniquement les coûts de perte d'exploitation, peu d'études ayant été consacrées à l'évaluation des coûts totaux ou aux méthodes permettant de déterminer le niveau optimal de la prévention. Les défis futurs consisteront à élaborer des cadres permettant d'aider les décideurs à déterminer les niveaux optimaux de la prévention des maladies endémiques.

Buena parte de los recursos del mundo se destinan a la obtención de productos de origen animal. Para alcanzar mayores cotas de bienestar social es importante pues utilizar esos recursos de modo eficiente. Las enfermedades animales endémicas merman la eficiencia productiva porque exigen una mayor cantidad de insumos para obtener el mismo nivel de producción o, alternativamente, reducen la producción obtenida por una misma cantidad de insumos. El nivel óptimo de producción, en presencia y en ausencia de enfermedades, difiere de una explotación a otra y depende de parámetros económicos que son variables. Estas dificultades explican por qué resulta tan arduo hacer una estimación teórica precisa del impacto económico de enfermedades endémicas. De ahí que los métodos actuales para evaluar en clave económica las enfermedades endémicas revistan un carácter bastante empírico. En lo que concierne a las decisiones adoptadas en el ámbito de la explotación, el costo total está formado por las pérdidas de explotación y los costos de prevención. Las pérdidas de explotación vienen determinadas por las pérdidas productivas (menor producción de leche, mortalidad y animales sacrificados), el costo de los tratamientos (servicios veterinarios, medicamentos y leche desechada a consecuencia del tratamiento) y el uso de otros recursos ligados a la aparición de la enfermedad (mayores costes laborales). Los costos de prevención, que son aquellos vinculados a las medidas profilácticas, corresponden al equipo empleado, los bienes consumibles (como productos químicos o de diagnóstico) y la utilización de otros recursos para prevenir enfermedades (mayores costes laborales). Existe una relación de sustitución entre las pérdidas de explotación y los costos de prevención. Ello significa que, para que una explotación rinda el máximo beneficio, conviene fijar la cantidad de recursos invertidos en prevención de tal manera que ello reduzca al mínimo los costos totales. La enfermedad endémica más estudiada en producción animal es la mastitis. En la mayoría de las publicaciones que se le han dedicado solo se evalúan las pérdidas de explotación, y en cambio escasean los estudios encaminados a evaluar los costos totales o a definir el mejor método para determinar el nivel óptimo de prevención. De cara al futuro, se trata de buscar modelos que puedan ayudar a las instancias decisorias a fijar los niveles óptimos de prevención de enfermedades endémicas.

Economics for assisting policy-makers to take decisions about new and endemic diseases.

Animal health policy-makers are frequently faced with making decisions concerning the control and exclusion of diseases in livestock and wildlife populations. Economics is one of the tools they have to aid their decision-making. It can enable them to make objective decisions based on the expected costs and benefits of their policy. In addition, economics can help them determine both the distribution impact and the indirect impact of their decisions. However, economics is only one of many tools available to policy-makers, who also need to consider non-economic outcomes in their decision-making process. While there are sophisticated epidemic and economic (epinomic) models that are available to help evaluate complex problems, these models typically require extensive data and well-trained analysts to run and interpret their results. In addition, effective communication between analysts and policy-makers is important to ensure that results are clearly conveyed to the policy-makers. This may be facilitated by early and continued discussions between these two potentially disparate groups. If successfully performed and communicated, economic analyses may present valuable information to policy-makers, enabling them to not only better understand the economic implications of their policy, but also to communicate the policy to relevant stakeholders, further ensuring their likelihood of participating in the planned policy and hence increasing its likelihood of success.

Les responsables des politiques de santé animale sont souvent confrontés à la nécessité de prendre des décisions au sujet de la lutte à mener contre les maladies animales affectant les populations domestiques et sauvages ou de leur éradication. L'économie est l'un des outils d'aide à la décision à leur disposition. L'économie peut les aider à prendre des décisions objectives basées sur les coûts et les avantages attendus des politiques envisagées. Elle peut aussi les aider à déterminer l'impact de leurs décisions en termes de portée et d'effets indirects. Néanmoins, l'économie n'est qu'un des nombreux outils disponibles et les décideurs doivent également intégrer les résultats non économiques lors de leur processus décisionnel. Un certain nombre de modèles épidémiques et économiques (« épinomiques ¼) sophistiqués permettent d'évaluer des problèmes complexes ; ils nécessitent cependant un volume considérable de données ainsi que des analystes qualifiés pour les mettre en oeuvre et en interpréter les résultats. En outre, une communication efficace doit être mise en place entre les analystes et les décideurs afin de s'assurer que les résultats obtenus sont rapportés à ces derniers dans un langage clair. Ceci peut être facilité par des échanges précoces et permanents entre ces deux groupes potentiellement hétérogènes. Des analyses économiques bien réalisées et faisant l'objet d'une bonne communication fournissent aux décideurs des informations de qualité grâce auxquelles ils peuvent appréhender plus clairement les conséquences économiques de leurs politiques, mais aussi expliquer ces politiques aux principales parties prenantes, ce qui accroît la probabilité de les faire adhérer aux mesures planifiées et améliore d'autant les chances de succès.

Los planificadores de políticas zoosanitarias se ven con frecuencia en la tesitura de adoptar decisiones acerca del control y la exclusión de enfermedades en poblaciones de ganado o de animales salvajes. La economía es una de las herramientas en las que pueden apoyarse para ello, pues les ayuda a tomar decisiones objetivas basándose en los costos y beneficios previstos de determinada política. Además, la economía puede serles útil para determinar tanto el impacto distributivo como el impacto indirecto de sus decisiones. Sin embargo, la economía es solo una de las muchas herramientas de que disponen los planificadores, que en su proceso decisorio también deben tener en cuenta efectos de carácter no económico. Si bien para ayudarles a aprehender problemas complejos existen sofisticados modelos epidemiológicos y económicos (epinómicos), estos suelen requerir un gran número de datos, así como el concurso de analistas cualificados para aplicar los modelos e interpretar sus resultados. Asimismo, para que los resultados obtenidos por los analistas lleguen con claridad a los planificadores es importante que existan cauces eficaces de comunicación entre los primeros y los segundos, lo que puede verse facilitado si estos dos grupos, en potencia tan dispares, dialogan desde buen comienzo y de forma continua. Si se llevan a cabo y se comunican correctamente, los análisis económicos pueden ofrecer información útil a los planificadores, que les sirva no solo para aprehender mejor las consecuencias económicas de sus políticas, sino también para explicar determinada política a todos los interlocutores del sector, con lo cual estos serán más proclives a participar en dicha política y esta tendrá más probabilidades de éxito.

Insights for the assessment of the economic impact of endemic diseases: specific adaptation of economic frameworks using the case of bovine viral diarrhoea.

Generic frameworks for the economic analysis of farm animal disease are now well established. The paper, therefore, uses bovine viral diarrhoea (BVD) as an example to explore how these frameworks need to be adapted to fit the characteristics of a particular disease and the specific objectives of the analysis. In the case of BVD, given the relative strength of tests available to correctly identify virus-positive animals, thus enabling them to be culled, the emphasis has been on cost-benefit analysis of regional and national certification/eradication schemes. Such analyses in turn raise interesting questions about farmer uptake and maintenance of certification schemes and the equity and cost-effective implementation of these schemes. The complex epidemiology of BVD virus infections and the long-term, widespread and often occult nature of BVD effects make economic analysis of the disease and its control particularly challenging. However, this has resulted in a wider whole-farm perspective that captures the influence of multiple decisions, not just those directly associated with disease prevention and control. There is a need to include management of reproduction, risk and enterprise mix in the research on farmer decision-making, as all these factors impinge on, and are affected by, the spread of BVD.

Les cadres généraux de l'analyse économique des maladies affectant les animaux d'élevage sont désormais bien établis. Les auteurs utilisent l'exemple de la diarrhée virale bovine pour définir les adaptations à apporter à ces cadres afin d'intégrer les caractéristiques d'une maladie donnée et les objectifs spécifiques de l'analyse. Dans le cas de la diarrhée virale bovine, compte tenu de la robustesse des tests disponibles pour détecter les animaux infectés (qui seront abattus), l'accent est mis sur l'analyse coûts-bénéfices des dispositifs régionaux et nationaux de certification sanitaire et d'éradication. Ces analyses soulèvent des questions intéressantes quant à l'engagement et à la persévérance des éleveurs à l'égard des dispositifs de certification et à la mise en oeuvre équitable et rentable de ces dispositifs. La complexité de l'infection due au virus de la diarrhée virale bovine et le caractère durable, répandu et souvent inapparent de ses effets rendent particulièrement difficiles les analyses économiques de cette maladie et de son contrôle. Ces analyses ont toutefois permis de mieux appréhender la situation dans la perspective d'une exploitation, en tenant compte des effets de décisions multiples qui ne se limitent pas à celles directement destinées à prévenir et à contrôler la maladie. La gestion de la reproduction, la gestion des risques et les choix de diversification doivent impérativement être intégrés dans la recherche sur les processus décisionnaires des éleveurs, car tous ces aspects affectent et sont affectés par la propagation de la diarrhée virale bovine.

Hoy en día ya existen modelos genéricos sobradamente contrastados para analizar en clave económica las enfermedades de los animales de granja. Partiendo de esta realidad, los autores utilizan el ejemplo de la diarrea viral bovina (DVB) para determinar el modo de adaptar esos modelos genéricos para que encajen con las características de una enfermedad en particular y con los objetivos específicos de un determinado análisis. En el caso de la DVB, teniendo en cuenta la relativa solidez de los ensayos existentes para identificar correctamente a los animales infectados (para su posterior sacrificio), los autores se centraron en analizar la relación costo-beneficio que presentan algunos dispositivos regionales y nacionales de certificación sanitaria o erradicación. Estos análisis, a su vez, abren interesantes interrogantes sobre el nivel de adhesión y perseverancia de los productores respecto de los programas de certificación y sobre el grado de equidad y rentabilidad con que se aplican esos dispositivos. La compleja epidemiología de las infecciones por el virus de la DVB y el carácter duradero, extendido y a menudo oculto de sus efectos dificultan especialmente el análisis en clave económica de la enfermedad y de las medidas para combatirla. Sin embargo, estos análisis han permitido aprehender desde una perspectiva más amplia la situación de la explotación en su conjunto, teniendo en cuenta la influencia de múltiples decisiones, y no solo de aquellas directamente relacionadas con la prevención y el control de la enfermedad. En toda investigación sobre el proceso decisorio de los productores es necesario tener en cuenta la gestión de la reproducción, la gestión de los riesgos y el tipo de actividades de la explotación, pues todos estos factores influyen en la propagación de la DVB y son influidos por ella.

Is the absence or intermittent YF vaccination the major contributor to its persistent outbreaks in eastern Africa?

Despite the availability of a safe and efficacious yellow fever vaccine since 1937, yellow fever remains a public health threat as a re-emerging disease in Africa and South America. We reviewed the trend of reported yellow fever outbreaks in eastern African countries, identified the risk epidemiological factors associated with the outbreaks and assessed the current situation of Yellow Fever vaccination in Africa. Surveillance and case finding for yellow fever in Africa are insufficient primarily due to lack of appropriate diagnostic capabilities, poor health infrastructure resulting in under-recognition, underreporting and underestimation of the disease. Despite these challenges, Ethiopia reported 302,614 cases (30,505 deaths) in 1943-2015, Kenya had 207 cases (38 deaths) in 1992-2016, Sudan experienced 31,750 suspected cases (1855 deaths) from 1940 to 2012 and Uganda had 452 cases (65 deaths) in 1941-2016. Major risk factors associated with past yellow fever outbreaks include climate, human practices and virus genetics. Comparisons between isolates from different outbreaks after 45 years have revealed the genetic stability of the structural proteins of YFV which are the primary targets of the host immune cells. This probably explains why yellow fever 17D vaccine is considered as outstandingly efficacious and safe after being used for 75 years. However, the 14 amino-acid changes among these isolates may have a greater impact on the changing disease epidemiology, virulence and transmission rate. Low population immunity against YF influences outbreak frequency especially in countries where the incorporation of YF vaccination is not combined with mass vaccination campaigns or vaccination is limited to international travellers. Understanding Yellow fever virus epidemiology as determined by its evolution underscores appropriate disease mitigation strategies and immunization policies. Mobilizing scarce resources to enhance population immunity through sufficient vaccination, promoting environmental sanitation/hygienic practices, driving behavioral change and community-based vector control are significant to preventing future epidemics.

Economic Costs and Benefits of a Community-Based Lymphedema Management Program for Lymphatic Filariasis in Odisha State, India.

Lymphatic filariasis afflicts 68 million people in 73 countries, including 17 million persons living with chronic lymphedema. The Global Programme to Eliminate Lymphatic Filariasis aims to stop new infections and to provide care for persons already affected, but morbidity management programs have been initiated in only 24 endemic countries. We examine the economic costs and benefits of alleviating chronic lymphedema and its effects through a simple limb-care program. For Khurda District, Odisha State, India, we estimated lifetime medical costs and earnings losses due to chronic lymphedema and acute dermatolymphangioadenitis (ADLA) with and without a community-based limb-care program. The program would reduce economic costs of lymphedema and ADLA over 60 years by 55%. Savings of US$1,648 for each affected person in the workforce are equivalent to 1,258 days of labor. Per-person savings are more than 130 times the per-person cost of the program. Chronic lymphedema and ADLA impose a substantial physical and economic burden on the population in filariasis-endemic areas. Low-cost programs for lymphedema management based on limb washing and topical medication for infection are effective in reducing the number of ADLA episodes and stopping progression of disabling and disfiguring lymphedema. With reduced disability, people are able to work longer hours, more days per year, and in more strenuous, higher-paying jobs, resulting in an important economic benefit to themselves, their families, and their communities. Mitigating the severity of lymphedema and ADLA also reduces out-of-pocket medical expense.

Elimination of Routine Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: A Retrospective Quasi-Experimental Study.

OBJECTIVE To evaluate the impact of discontinuation of contact precautions (CP) for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) and expansion of chlorhexidine gluconate (CHG) use on the health system. DESIGN Retrospective, nonrandomized, observational, quasi-experimental study. SETTING Two California hospitals. PARTICIPANTS Inpatients. METHODS We compared hospital-wide laboratory-identified clinical culture rates (as a marker of healthcare-associated infections) 1 year before and after routine CP for endemic MRSA and VRE were discontinued and CHG bathing was expanded to all units. Culture data from patients and cost data on material utilization were collected. Nursing time spent donning personal protective equipment was assessed and quantified using time-driven activity-based costing. RESULTS Average positive culture rates before and after discontinuing CP were 0.40 and 0.32 cultures/100 admissions for MRSA (P=.09), and 0.48 and 0.40 cultures/100 admissions for VRE (P=.14). When combining isolation gown and CHG costs, the health system saved $643,776 in 1 year. Before the change, 28.5% intensive care unit and 19% medicine/surgery beds were on CP for MRSA/VRE. On the basis of average room entries and donning time, estimated nursing time spent donning personal protective equipment for MRSA/VRE before the change was 45,277 hours/year (estimated cost, $4.6 million). CONCLUSION Discontinuing routine CP for endemic MRSA and VRE did not result in increased rates of MRSA or VRE after 1 year. With cost savings on materials, decreased healthcare worker time, and no concomitant increase in possible infections, elimination of routine CP may add substantial value to inpatient care delivery. Infect Control Hosp Epidemiol 2016;1-8.

Cost of Dengue Vector Control Activities in Malaysia.

Dengue fever, an arbovirus disease transmitted by Aedes mosquitoes, has recently spread rapidly, especially in the tropical countries of the Americas and Asia-Pacific regions. It is endemic in Malaysia, with an annual average of 37,937 reported dengue cases from 2007 to 2012. This study measured the overall economic impact of dengue in Malaysia, and estimated the costs of dengue prevention. In 2010, Malaysia spent US$73.5 million or 0.03% of the country's GDP on its National Dengue Vector Control Program. This spending represented US$1,591 per reported dengue case and US$2.68 per capita population. Most (92.2%) of this spending occurred in districts, primarily for fogging. A previous paper estimated the annual cost of dengue illness in the country at US$102.2 million. Thus, the inclusion of preventive activities increases the substantial estimated cost of dengue to US$175.7 million, or 72% above illness costs alone. If innovative technologies for dengue vector control prove efficacious, and a dengue vaccine was introduced, substantial existing spending could be rechanneled to fund them.

A cost-effectiveness analysis of a program to control rheumatic fever and rheumatic heart disease in Pinar del Rio, Cuba.

BACKGROUND: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) persist in many low- and middle-income countries. To date, the cost-effectiveness of population-based, combined primary and secondary prevention strategies has not been assessed. In the Pinar del Rio province of Cuba, a comprehensive ARF/RHD control program was undertaken over 1986-1996. The present study analyzes the cost-effectiveness of this Cuban program. METHODS AND FINDINGS: We developed a decision tree model based on the natural history of ARF/RHD, comparing the costs and effectiveness of the 10-year Cuban program to a "do nothing" approach. Our population of interest was the cohort of children aged 5-24 years resident in Pinar del Rio in 1986. We assessed costs and health outcomes over a lifetime horizon, and we took the healthcare system perspective on costs but did not apply a discount rate. We used epidemiologic, clinical, and direct medical cost inputs that were previously collected for publications on the Cuban program. We estimated health gains as disability-adjusted life years (DALYs) averted using standard approaches developed for the Global Burden of Disease studies. Cost-effectiveness acceptability thresholds were defined by one and three times per capita gross domestic product per DALY averted. We also conducted an uncertainty analysis using Monte Carlo simulations and several scenario analyses exploring the impact of alternative assumptions about the program's effects and costs. We found that, compared to doing nothing, the Cuban program averted 5051 DALYs (1844 per 100,000 school-aged children) and saved $7,848,590 (2010 USD) despite a total program cost of $202,890 over 10 years. In the scenario analyses, the program remained cost saving when a lower level of effectiveness and a reduction in averted years of life lost were assumed. In a worst-case scenario including 20-fold higher costs, the program still had a 100% of being cost-effective and an 85% chance of being cost saving. CONCLUSIONS: A 10-year program to control ARF/RHD in Pinar del Rio, Cuba dramatically reduced morbidity and premature mortality in children and young adults and was cost saving. The results of our analysis were robust to higher program costs and more conservative assumptions about the program's effectiveness. It is possible that the program's effectiveness resulted from synergies between primary and secondary prevention strategies. The findings of this study have implications for non-communicable disease policymaking in other resource-limited settings.

[Schistosomiasis monitoring and its cost in population in Danyang City, 2010-2014].

OBJECTIVE: To explore the monitoring method of the infection source of schistosomiasis in the population of the schistosomiasis transmission-interrupted area with Oncomelania hupensis snails. METHODS: The changes of schistosomiasis among the population were investigated by using the active and passive monitoring methods in Danyang City from 2010 to 2014, and the cost-effectiveness of the two monitoring methods was evaluated. RESULTS: Totally 49,277 persons were detected for schistosomiasis by dipstick dye immunoassay (DDIA) from 2010 to 2014 and 608 cases were positive, and the positive rate was 1.23%. There were no positive persons by etiology detections. The positive rates of active and passive monitoring methods were 1.61% and 1.13%, respectively and there was a significant difference between them (χ² = 15.982, P < 0.05). The average cost per positive case of the active monitoring was higher than that of the passive monitoring without considering the costs of the mobilization and labor. CONCLUSION: In the schistosomiasis transmission-interrupted area with snails, the active and passive monitoring methods need to be combined in the future.