'My feet cannot stand on their own': podoconiosis patient healthcare expenditures and income impacts in Rwanda.

BACKGROUND: Podoconiosis is a progressive and debilitating form of tropical lymphoedema endemic to Rwanda. Although the physical and psychological consequences are well known, few studies have evaluated the financial burden of podoconiosis. METHODS: This cross-sectional, quantitative study aimed to characterize direct treatment costs and impacts on annual earnings among individuals living with podoconiosis. Participants from two highly endemic districts were invited to complete a survey focused on health-seeking history, insurance status, out-of-pocket costs and income changes. Direct treatment costs included medical expenditures (consultation, diagnostics, medication) and non-medical expenditures (food, transportation, accommodation). RESULTS: Overall, 226 adults (≥18 y of age) diagnosed with podoconiosis participated. Most had access to community-based health insurance (91.6%) but were unable to work (71.7%). Respondents sought care from health centres/posts (61.9%), hospitals (25.1%), traditional healers (5.8%) and/or community health workers (4.0%). On average, study participants paid US$32.50 (range US$0-779.23) annually, or 11.7% of their household salary, on podoconiosis treatments. CONCLUSIONS: This study demonstrates the significant financial burden of podoconiosis on individuals and their communities. Increased attention on integrating podoconiosis management into primary care systems and testing cost-effective solutions is needed to protect those who are most vulnerable.

Estimating the Incidence and Economic Cost of Lyme Disease Cases in Canada in the 21st Century with Projected Climate Change.

BACKGROUND: Lyme disease (LD) is emerging in Canada owing to the range expansion of the tick vector Ixodes scapularis (I. scapularis). OBJECTIVES: Our objective was to estimate future LD incidence in Canada, and economic costs, for the 21st century with projected climate change. METHODS: Future regions of climatic suitability for I. scapularis were projected from temperature output of the North American Coordinated Regional Climate Downscaling Experiment regional climate model ensemble using greenhouse gas Representative Concentration Pathways (RCPs) 4.5 and 8.5. Once regions became climatically suitable for ticks, an algorithm derived from tick and LD case surveillance data projected subsequent increasing LD incidence. Three scenarios (optimistic, intermediate, and pessimistic) for maximum incidence at endemicity were selected based on LD surveillance, and underreporting estimates, from the United States. Health care and productivity cost estimates of LD cases were obtained from the literature. RESULTS: Projected annual LD cases for Canada ranged from 120,000 to >500,000 by 2050. Variation in incidence was mostly due to the maximum incidence at endemicity selected, with minor contributions from variations among climate models and RCPs. Projected annual costs were substantial, ranging from CA$0.5 billion to $2.0 billion a year by 2050. There was little difference in projected incidence and economic cost between RCPs, and from 2050 to 2100, because projected climate up to 2050 is similar for RCP4.5 and RCP8.5 (mitigation of greenhouse gas emissions captured in RCP4.5 does not impact climate before the 2050s) and by 2050 the most densely populated areas of the study region are projected to be climatically suitable for ticks. CONCLUSIONS: Future incidence and economic costs of LD in Canada are likely to be substantial, but uncertainties remain. Because densely populated areas of Canada are projected to become endemic under conservative climate change scenarios, mitigation of greenhouse gas emissions is unlikely to provide substantial health co-benefits for LD. https://doi.org/10.1289/EHP13759.

"I sold my towel and shoes to pay the traditional healer": Care-seeking costs and productivity losses among snakebite victims in Eastern Province, Rwanda.

Snakebite envenomation (SBE) is endemic to sub-Saharan Africa and generally over-represented in rural, remote, and impoverished agricultural communities. While poverty is an established risk factor, little research has been done to investigate the economic consequences of SBE. This cross-sectional, quantitative study aimed to measure out-of-pocket spending and lost income when a household member was bitten by a snake. In 2020, 732 snakebite survivors from Eastern Province (Rwanda) agreed to complete a survey administered by telephone. The survey focused on participant demographics, income, direct medical and non-medical costs, care-seeking decisions, and lost work during convalescence. Our results suggested that patients incurred the highest mean expenses when they sought care from hospitals (11 307 RWF or 12 USD) or traditional healers (5 836 RWF or 6 USD) but that the highest maximum cost was incurred from traditional healers (300 000 RWF or 313 USD). Across all victims, the total amount paid to traditional healers (3.4 million RWF or 3 537 USD) was 4.7 times higher than all other care providers combined. On average, families lost 111 814 RWF (117 USD) per snakebite in direct treatment costs and indirect productivity losses. Many victims sought care from traditional healers despite being eligible for free medical care. Altogether, this study serves as a reminder of the serious physical and financial consequences associated with SBE and provides justification for new investments into SBE prevention and care.

Sex differences in adverse events following seasonal influenza vaccines: a meta-analysis of randomised controlled trials.

BACKGROUND: Despite being a vaccine-preventable disease, influenza remains a major public health threat with vaccine safety concerns reducing vaccine acceptability. Immune responses to vaccines and adverse events may differ between males and females, but most studies do not report results by sex. Using data from clinical trials, we explored sex differences in adverse events following seasonal influenza vaccines. METHODS: We obtained data for phase III randomised controlled trials identified through a systematic review and clinical trials registries, and performed a two-stage meta-analysis. Risk ratios (RR) and 95% confidence intervals (95% CI) comparing solicited reactions in females versus males were pooled using the Mantel-Haenszel method and a random-effects model. We used the ROBINS-I tool to assess risk of bias and the I2 statistic for heterogeneity. Main analysis was stratified by age: 18-64 years and ≥65 years. RESULTS: The dataset for this analysis included 34 343 adults from 18 studies (12 with individual-level data and 6 with aggregate data). There was a higher risk of injection site reactions in females compared with males for both younger and older participants, with RRs of 1.29 (95% CI 1.21 to 1.37) and 1.43 (95% CI 1.28 to 1.60), respectively. Higher risk in females was also observed for systemic reactions, with RRs of 1.25 (95% CI 1.20 to 1.31) and 1.27 (95% CI 1.20 to 1.34) for younger and older participants, respectively. We also observed elevated risks of severe reactions in females, with a higher RR in younger versus older participants for systemic reactions (RRs 2.12 and 1.48, p=0.03, I2=79.7%). RRs were not found to vary between quadrivalent and trivalent vaccines. CONCLUSION: This meta-analysis suggested a higher risk of solicited reactions following influenza vaccines for females compared with males, irrespective of age and vaccine type. Transparent communication of this risk could increase the trust in vaccines and limit vaccine hesitancy. Future studies should report results stratified by sex and explore the role of gender in the occurrence of adverse events.

Healthcare costs and effects of post-COVID-19 condition in Canada.

Background: As evidence of the long-term health impacts of coronavirus disease 2019 (COVID-19) continues to grow across Canada, a key concern is the costs and health impacts of post-COVID-19 condition (PCC), especially while the healthcare system remains under substantial strain. The objective of this study is to estimate healthcare costs and quality-adjusted life year (QALY) decrements per PCC case and per acute COVID-19 case by vaccination status. Methods: First, we conducted a rapid review of the literature to estimate 1) the probability of developing PCC following COVID-19 infection by vaccination status, 2) the probability of each condition commonly associated with PCC, 3) healthcare costs and QALY decrements associated with each condition and 4) the number of PCC cases currently in Canada. Second, using the data gathered from the literature, we built a tool to estimate the cost and QALY decrements per PCC and COVID-19 case. Results: Post-COVID-19 condition costs per COVID-19 case ranged from CAD 1,675 to CAD 7,340, and QALY decrements ranged between 0.047 to 0.206, in the first year following COVID-19 infection. Overall, individuals who were unvaccinated when they were infected had higher costs and QALY decrements. We estimated the total burden of PCC to the Canadian healthcare system based on PCC estimates up until spring 2023 would be between CAD 7.8 and CAD 50.6 billion. Conclusion: This article demonstrates the large potential health and economic burden of PCC for Canadians, and the importance of vaccination and other infection control strategies in reducing the longer-term costs and effects.

Quantifying the economic gains associated with COVID-19 vaccination in the Canadian population: A cost-benefit analysis.

Background: Vaccination has been a key part of Canada's coronavirus disease 2019 (COVID-19) pandemic response. Although the clinical benefits of vaccination are clear, an understanding of the population-level benefits of vaccination relative to the programmatic costs is of value. The objective of this article is to quantify the economic impact of COVID-19 vaccination in the Canadian population between December 2020 and March 2022. Methods: We conducted a model-based cost-benefit analysis of Canada's COVID-19 vaccination program. We used an epidemiological model to estimate the number of COVID-19 symptomatic cases, hospitalizations, post-COVID condition (PCC) cases, and deaths in the presence and absence of vaccination. Median, lower and upper 95% credible interval (95% CrI) outcome values from 100 model simulations were used to estimate the direct and indirect costs of illness, including the value of health. We used a societal perspective and a 1.5% discount rate. Results: We estimated that the costs of the vaccination program were far outweighed by the savings associated with averted infections and associated downstream consequences. Vaccination increased the net benefit by CAD $298.1 billion (95% CrI: 27.2-494.6) compared to the no vaccination counterfactual. The largest benefits were due to averted premature mortality, resulting in an estimated $222.0 billion (95% CrI: 31.2-379.0) benefit. Conclusion: Our model-based economic evaluation provides a retrospective assessment of COVID-19 vaccination during the first 16 months of the program in Canada and suggests that it was welfare-improving, considering the decreased hospitalizations and use of healthcare resources, deaths averted and lower morbidity from conditions such as PCC.

Economic evaluation of COVID-19 rapid antigen screening programs in the workplace.

BACKGROUND: Diagnostic testing has been pivotal in detecting SARS-CoV-2 infections and reducing transmission through the isolation of positive cases. We quantified the value of implementing frequent, rapid antigen (RA) testing in the workplace to identify screening programs that are cost-effective. METHODS: To project the number of cases, hospitalizations, and deaths under alternative screening programs, we adapted an agent-based model of COVID-19 transmission and parameterized it with the demographics of Ontario, Canada, incorporating vaccination and waning of immunity. Taking into account healthcare costs and productivity losses associated with each program, we calculated the incremental cost-effectiveness ratio (ICER) with quality-adjusted life year (QALY) as the measure of effect. Considering RT-PCR testing of only severe cases as the baseline scenario, we estimated the incremental net monetary benefits (iNMB) of the screening programs with varying durations and initiation times, as well as different booster coverages of working adults. RESULTS: Assuming a willingness-to-pay threshold of CDN$30,000 per QALY loss averted, twice weekly workplace screening was cost-effective only if the program started early during a surge. In most scenarios, the iNMB of RA screening without a confirmatory RT-PCR or RA test was comparable or higher than the iNMB for programs with a confirmatory test for RA-positive cases. When the program started early with a duration of at least 16 weeks and no confirmatory testing, the iNMB exceeded CDN$1.1 million per 100,000 population. Increasing booster coverage of working adults improved the iNMB of RA screening. CONCLUSIONS: Our findings indicate that frequent RA testing starting very early in a surge, without a confirmatory test, is a preferred screening program for the detection of asymptomatic infections in workplaces.

Using Health Economics to Inform Immunization Policy Across All Levels of Government.

Publicly funded immunization programs have grown in both complexity and scope, resulting in increased costs and more complex programmatic decision making. Economic evaluations can provide crucial information to support informed decision making. While very few countries have National Immunization Technical Advisory Groups that analyze economic information, many have started to develop processes for this purpose. Since these guidelines are being developed at the national level, we propose that regional jurisdictions, especially those responsible for healthcare (e.g., provinces, territories, states), need clear processes for incorporating this information into their immunization decision making and program implementation. We interviewed Canadian vaccine experts involved in provincial vaccine policy decision making to identify current practices, perceptions, and recommendations around incorporating economic analysis into that process. Based on these interviews, we make five recommendations: (1) economic evidence should be routinely incorporated into the decision making process; (2) economic experts should sit on, or be available to, regional advisory committees; (3) efforts should be made to build on regional expertise by increasing educational opportunities on economic evaluation; (4) processes should include guidelines for when economic analysis is not required; and (5) clarification on the role of regional advisory groups in economic analysis is needed in relation to national expertise. The information presented here provides a starting point for regional health policy experts and decision makers to work collaboratively with national partners to create transparent and effective approaches to incorporating economic analysis into vaccine decision making.

A cost analysis of the diagnosis and treatment of malaria at public health facilities and communities in three districts in Rwanda.

BACKGROUND: Malaria is a potentially fatal disease spread by the bites of Plasmodium-infected Anopheles mosquitoes. Despite long-term efforts to control malaria in Rwanda, malaria incidence increased from 48 to 403 cases/1000 individuals between 2012 and 2016. The diagnosis and treatment of malaria occurs at multiple levels, but the costs of these activities are not well understood. This research was conducted to estimate the direct medical costs incurred by the Ministry of Health in diagnosing and treating malaria in three districts of Rwanda in 2018. METHODS: A cross-sectional and retrospective costing analysis was conducted in three districts that represented low (5-200 cases per 1000 individuals), moderate (> 200-400 cases per 1000 individuals), and high (> 400 cases per 1000 individuals) endemicity regions. Data on malaria cases managed at three healthcare levels (community, health centre, district hospital) was obtained from national databases. The direct medical costs of cases per malaria severity ('simple malaria', 'simple malaria with minor digestive symptoms', and 'severe malaria') were calculated based on the minimum package of health services provided. Total costs for each of the three districts were also calculated. RESULTS: A total of 298,381 malaria cases were recorded in Burera, Kirehe, and Southern Kayonza districts in 2018. The average unit cost per case ranged from USD 1.36 (for simple malaria at the community level) to USD 92.80 (for severe malaria with cerebral complications at district hospitals). Simple malaria cases managed at health centres and district hospitals were more than two-fold (USD 2.99-USD 3.00) and more than eight-fold (USD 12.10-USD 12.12) higher, respectively, than those managed in the community (USD 1.36). Overall, the Ministry of Health incurred USD 645,647.68 in direct medical costs related to malaria management across the three districts in 2018. Changes in disease rates from different endemicity regions and costs of anti-malarial oral medications significantly impacted the study results. CONCLUSION: In Rwanda, severe malaria results in much higher expenses compared to other malaria types. Prompt diagnosis and appropriate treatment are crucial to prevent the progression of simple malaria to severe malaria, to reduce Ministry of Health malaria expenditures, and to reduce community transmission.

Evaluating the Individual Healthcare Costs and Burden of Disease Associated with RSV Across Age Groups.

BACKGROUND: Respiratory syncytial virus (RSV) is a major cause of acute respiratory infection (ARI), with high morbidity and mortality worldwide. RSV costing and burden estimates can highlight the potential benefits of future vaccination programs and are essential for economic evaluations. OBJECTIVE: We aimed to determine RSV healthcare costs across age groups and the overall disease burden of medically attended RSV in Canada. METHODS: We conducted a retrospective case-control study to estimate the attributable healthcare costs per RSV case in Alberta. We used two case definitions to capture diversity in case severity: laboratory-confirmed RSV and ARI attributable to RSV. Matching occurred on five criteria: (1) age, (2) urban/rural status, (3) sex, (4) prematurity and (5) Charlson Comorbidity Index score. We calculated the age-specific burden of medically attended RSV in Canada from 2010 to 2019 by multiplying the weekly age-specific incidence of medically attended ARI with the RSV positivity rate. RESULTS: Costs per laboratory-confirmed RSV case were (in Canadian dollars [CAD], year 2020 values) $CAD12,713 and 40,028 in the first 30 and 365 days following diagnosis, respectively, whereas a case of ARI potentially attributable to RSV cost $CAD316 and 915, in 30 and 365 days, respectively. Older (aged ≥ 65 years) and younger (aged < 90 days) age groups had the highest case costs. The average medically attended RSV incidence rate across nine seasons was 1743 cases per 100,000 people per year. CONCLUSIONS: RSV is a common and expensive infection at the extremes of life, and the development of immunization programs targeting older and younger ages may be important for the reduction of RSV burden and cost.

Impact of the COVID-19 pandemic on vaccine coverage for early childhood vaccines in Alberta, Canada: a population-based retrospective cohort study.

OBJECTIVE: To assess the impact of the COVID-19 pandemic on early childhood vaccination coverage in Alberta, Canada. SETTING: Alberta, a western Canadian province, which has a population of 4.4 million and approximately 50 000 births annually. DESIGN: In this retrospective cohort study, population-based administrative health data were analysed to determine the vaccination coverage for measles-containing, pertussis-containing and rotavirus vaccines. PRIMARY OUTCOME MEASURE: We measured monthly and cumulative vaccine coverage. We assessed the absolute difference in monthly and cumulative coverage for each vaccine dose by comparing children due for vaccination in each month of 2019 and 2020, with follow-up to determine if missed doses were caught up later. PARTICIPANTS: We included 114 178 children in the 2019 analysis cohort and 106 530 children in the 2020 analysis cohort. RESULTS: Monthly vaccination coverage in 2020 was higher than 2019 until March, when coverage significantly declined. Comparing April 2020 to 2019, coverage was 9.9% (95% CI 7.9% to 12.0%) lower for measles vaccine; 4.9% (95% CI 3.3% to 6.5%), 7.1% (95% CI 5.2% to 9.1%), 5.2% (95% CI 3.1% to 7.4%) and 8.8% (95% CI 6.6% to 10.9%) lower for first, second, third and fourth doses of pertussis-containing vaccine, respectively; and 4.0% (95% CI 2.3% to 5.7%), 7.1% (95% CI 5.1% to 9.2%) and 4.6% (95% CI 2.4% to 6.7%) lower for first, second and third doses of rotavirus vaccine, respectively. Monthly coverage improved during May to July 2020; however, some doses experienced a second decline during September to October 2020. The cumulative coverage analysis showed that the measles-containing vaccine had the largest difference in coverage at the end of follow-up. CONCLUSIONS: Children who were due for vaccination early in the pandemic and in Fall 2020, especially those due for measles vaccination, may require additional catch-up.

COVID-19 pandemic impact on childhood vaccination coverage in Quebec, Canada.

Response measures to mitigate the coronavirus disease 2019 pandemic impacted access to routine vaccination services. We evaluate the impact of the pandemic on routine infant vaccination uptake by comparing vaccination coverage, vaccine delays and doses administered in 2019 and 2020, in Quebec, Canada. Using a population-based vaccination registry, we compared vaccination coverage at 3, 5, 13 and 19 months of age between 2019 and 2020 cohorts each month from January to November. For vaccine delays, we measured the cumulative proportion vaccinated in each targeted cohort monthly. We also compared the measles-containing vaccines administered before 24 months of age between the same period in 2019 and 2020. A decline in vaccination coverage and children vaccinated on time was observed in all cohorts during the first months of the pandemic. The greatest impact was observed for the 18-month vaccination visit with a difference in vaccination coverage between both cohorts of 30.9% in May. Measles-containing doses administered during the first months of the pandemic were lower in 2020 compared with 2019: -21.1% in March (95%CI-21.6;-20.4), and -39.2% in April (95%CI-40.0;-38.2). After May, the coverage increased for all cohorts to reach pre-pandemic levels after a few months for most target ages. Routine childhood vaccinations were affected during the first months of the pandemic, but catch-up occurred thereafter and vaccination coverage in affected cohorts were very close to levels of 2019 after a few months of follow-up. Real-time monitoring of childhood vaccination is essential but also for other vaccination programs, severely affected by the pandemic.

A Net Benefit Approach for the Optimal Allocation of a COVID-19 Vaccine.

OBJECTIVE: The objective of this study was to implement a model-based approach to identify the optimal allocation of a coronavirus disease 2019 (COVID-19) vaccine in the province of Alberta, Canada. METHODS: We developed an epidemiologic model to evaluate allocation strategies defined by age and risk target groups, coverage, effectiveness and cost of vaccine. The model simulated hypothetical immunisation scenarios within a dynamic context, capturing concurrent public health strategies and population behavioural changes. RESULTS: In a scenario with 80% vaccine effectiveness, 40% population coverage and prioritisation of those over the age of 60 years at high risk of poor outcomes, active cases are reduced by 17% and net monetary benefit increased by $263 million dollars, relative to no vaccine. Concurrent implementation of policies such as school closure and senior contact reductions have similar impacts on incremental net monetary benefit ($352 vs $292 million, respectively) when there is no prioritisation given to any age or risk group. When older age groups are given priority, the relative benefit of school closures is much larger ($214 vs $118 million). Results demonstrate that the rank ordering of different prioritisation options varies by prioritisation criteria, vaccine effectiveness and coverage, and concurrently implemented policies. CONCLUSIONS: Our results have three implications: (i) optimal vaccine allocation will depend on the public health policies in place at the time of allocation and the impact of those policies on population behaviour; (ii) outcomes of vaccine allocation policies can be greatly supported with interventions targeting contact reduction in critical sub-populations; and (iii) identification of the optimal strategy depends on which outcomes are prioritised.

COVID-19 infection among international travellers: a prospective analysis.

OBJECTIVES: This report estimates the risk of COVID-19 importation and secondary transmission associated with a modified quarantine programme in Canada. DESIGN AND PARTICIPANTS: Prospective analysis of international asymptomatic travellers entering Alberta, Canada. INTERVENTIONS: All participants were required to receive a PCR COVID-19 test on arrival. If negative, participants could leave quarantine but were required to have a second test 6 or 7 days after arrival. If the arrival test was positive, participants were required to remain in quarantine for 14 days. MAIN OUTCOME MEASURES: Proportion and rate of participants testing positive for COVID-19; number of cases of secondary transmission. RESULTS: The analysis included 9535 international travellers entering Alberta by air (N=8398) or land (N=1137) that voluntarily enrolled in the Alberta Border Testing Pilot Programme (a subset of all travellers); most (83.1%) were Canadian citizens. Among the 9310 participants who received at least one test, 200 (21.5 per 1000, 95% CI 18.6 to 24.6) tested positive. Sixty-nine per cent (138/200) of positive tests were detected on arrival (14.8 per 1000 travellers, 95% CI 12.5 to 17.5). 62 cases (6.7 per 1000 travellers, 95% CI 5.1 to 8.5; 31.0% of positive cases) were identified among participants that had been released from quarantine following a negative test result on arrival. Of 192 participants who developed symptoms, 51 (26.6%) tested positive after arrival. Among participants with positive tests, four (2.0%) were hospitalised for COVID-19; none required critical care or died. Contact tracing among participants who tested positive identified 200 contacts; of 88 contacts tested, 22 were cases of secondary transmission (14 from those testing positive on arrival and 8 from those testing positive thereafter). SARS-CoV-2 B.1.1.7 lineage was not detected in any of the 200 positive cases. CONCLUSIONS: 21.5 per 1000 international travellers tested positive for COVID-19. Most (69%) tested positive on arrival and 31% tested positive during follow-up. These findings suggest the need for ongoing vigilance in travellers testing negative on arrival and highlight the value of follow-up testing and contact tracing to monitor and limit secondary transmission where possible.

The impact of varicella vaccination on paediatric herpes zoster epidemiology: a Canadian population-based retrospective cohort study.

The impact of universal varicella vaccination on herpes zoster (HZ) risk in unvaccinated and vaccinated children, and its long-term influence on HZ epidemiology, remains unknown. We conducted a retrospective cohort study using population-based administrative health data for children born between 1993 and 2018 (n = 924,124). We calculated age-specific cumulative HZ incidence rates by vaccination status for cohorts born before (1993-1999) and after (2000-2018) programme implementation; results were used to calculate relative risk of HZ by age group, vaccination status and vaccine availability period. Annual HZ incidence rates were calculated for 1993-2018. HZ risk was higher among unvaccinated children compared to vaccinated children across age groups; 64% higher before universal vaccination (RR: 0.36, 95% CI: 0.33, 0.39), and 32% higher after universal vaccination (RR: 0.68, 95% CI: 0.64, 0.73). Among unvaccinated children, HZ risk was 60% lower after vaccine programme implementation (RR: 0.40, 95% CI: 0.38, 0.43). Two-dose receipt corresponded with a 41% lower risk of HZ compared to one-dose receipt (RR: 0.59, 95% CI: 0.53, 0.65). Crude annual HZ incidence rates declined 64% after programme implementation, with decreases observed across age groups. Universal varicella vaccination programme implementation corresponds to decreased paediatric HZ incidence across age groups, in both vaccinated and unvaccinated individuals. Results from this study can be used to help inform varicella vaccination programme decision-making in other countries.

What We Know Now: An Economic Evaluation of Chickenpox Vaccination and Dose Timing Using an Agent-Based Model.

OBJECTIVES: The value of chickenpox vaccination is still debated in the literature and by jurisdictions worldwide. This uncertainty is reflected in the inconsistent uptake of the vaccine, where some countries offer routine childhood immunization programs, others have targeted programs, and in many the vaccine is only privately available. Even across the countries that have universal funding for the vaccine, there is a diversity of schedules and dosing intervals. Using an agent-based model of chickenpox and shingles, we conducted an economic evaluation of chickenpox vaccination in Alberta, Canada. METHODS: We compared the cost-effectiveness of 2 common chickenpox vaccination schedules, specifically a long dosing interval (first dose: 12 months; second dose: 4-6 years) and a short dosing interval (first dose: 12 months; second dose: 18 months). RESULTS: The economic evaluation demonstrated a shorter dosing interval may be marginally preferred, although it consistently led to higher costs from both the societal and healthcare perspectives. We found that chickenpox vaccination would be cost-saving and highly cost-effective from the societal and healthcare perspective, assuming there was no impact on shingles. CONCLUSION: Chickenpox vaccine was cost-effective when not considering shingles and remained so even if there was a minor increase in shingles following vaccination. However, if chickenpox vaccination did lead to a substantial increase in shingles, then chickenpox vaccination was not cost-effective from the healthcare perspective.

Equity for health delivery: Opportunity costs and benefits among Community Health Workers in Rwanda.

Community Health Workers (CHWs) play a vital role delivering health services to vulnerable populations in low resource settings. In Rwanda, CHWs provide village-level care focused on maternal/child health, control of infectious diseases, and health education, but do not receive salaries for these services. CHWs make up the largest single group involved in health delivery in the country; however, limited information is available regarding the socio-economic circumstances and satisfaction levels of this workforce. Such information can support governments aiming to control infectious diseases and alleviate poverty through enhanced healthcare delivery. The objectives of this study were to (1) evaluate CHW opportunity costs, (2) identify drivers for CHW motivation, job satisfaction and care provision, and (3) report CHW ideas for improving retention and service delivery. In this mixed-methods study, our team conducted in-depth interviews with 145 CHWs from three districts (Kirehe, Kayonza, Burera) to collect information on household economics and experiences in delivering healthcare. Across the three districts, CHWs contributed approximately four hours of volunteer work per day (range: 0-12 hrs/day), which translated to 127 684 RWF per year (range: 2 359-2 247 807 RWF/yr) in lost personal income. CHW out-of-pocket expenditures (e.g. patient transportation) were estimated at 36 228 RWF per year (range: 3 600-364 800 RWF/yr). Participants identified many benefits to being CHWs, including free healthcare training, improved social status, and the satisfaction of helping others. They also identified challenges, such as aging equipment, discrepancies in financial reimbursements, poverty, and lack of formal workspaces or working hours. Lastly, CHWs provided perspectives on reasonable and feasible improvements to village-level health programming that could improve conditions and equity for those providing and using the CHW system.

Is there a difference in the immune response, efficacy, effectiveness and safety of seasonal influenza vaccine in males and females? - A systematic review.

INTRODUCTION: Seasonal influenza is an important cause of morbidity and mortality, despite being vaccine-preventable. Sex factors (genes and hormones) seem to impact individuals' susceptibility to infectious diseases and their response to vaccination. However, most vaccine studies do not explicitly assess sex differences in vaccine response, but rather adjust for sex. METHODS: We conducted a systematic review to analyze immunogenicity, efficacy, effectiveness and/or safety of seasonal influenza vaccine data stratified by sex. We searched PubMed, EMBASE, CINAHL, Web of Science and clinicaltrials.gov for observational studies and phase III/IV trials from January 1990 to June 2018, published in English or French. Two reviewers independently screened all references, then proceeded to data extraction and quality assessment using the Cochrane tools (RoB and ROBINS-I) on included studies. RESULTS: Of the 5,745 citations retrieved, 46 studies were included in the SR. Overall, 18 studies assessed immunogenicity, 1 estimated efficacy, 6 measured effectiveness and 25 evaluated safety of seasonal influenza vaccine in females and males (four studies reported on two sex-stratified outcomes concomitantly). CONCLUSION: No clear conclusion could be drawn regarding the effect of sex on the immunogenicity and effectiveness of seasonal influenza vaccine, but higher rates of adverse events following immunization (AEFIs) were reported in females. The heterogeneity of data and studies' low quality prevented us from conducting a meta-analysis. There is a need to emphasize on the appropriate use of the terms sex and gender in biomedical research. Evidence of higher quality is needed to better understand sex differences in response to influenza vaccine.

Seeking the optimal schedule for chickenpox vaccination in Canada: Using an agent-based model to explore the impact of dose timing, coverage and waning of immunity on disease outcomes.

Many countries continue to consider implementing a universal chickenpox vaccine program; however, there is no consensus on the most appropriate and effective timing between vaccine doses. The chickenpox vaccine schedule debate is highlighted in Canada, where there are currently eight different vaccine schedules across the country. The objective of this study was to test the overall effectiveness of chickenpox vaccination, as well as the specific impact of two different vaccine schedules, on chickenpox disease outcomes in Alberta over 75 years. Using an agent-based model of chickenpox disease, we tested the impact of three vaccination scenarios including: baseline (no vaccination), a long dosing interval-Schedule LDI (1st dose - 12 months; 2nd dose -  4-6 years) and a short dosing interval-Schedule SDI (1st dose - 12 months; 2nd dose - 18 months) on chickenpox and shingles disease outcomes. Chickenpox vaccination led to a substantial decrease in chickenpox incidence over 75 years post-vaccine implementation. Compared to Schedule LDI, Schedule SDI resulted in a significantly lower chickenpox incidence, a higher age of chickenpox infection, a lower chickenpox breakthrough rate and a higher shingles incidence rate. Our model findings suggest that the chickenpox vaccine is effective over a long period of time and the dose timing of the vaccine may impact disease outcomes and vaccine effectiveness. However, the effectiveness of the vaccine dose timing is only one consideration for policy-makers who are implementing a chickenpox vaccine program, with others including risk of adverse events, the impact of the schedule on other antigens in a combination vaccine, parental acceptance and the cost associated with different schedules.

Measurement of coverage, compliance and determinants of uptake in a publicly funded rotavirus vaccination programme: a retrospective cohort study.

OBJECTIVES: In June 2015, Alberta, Canada instituted a universal publicly funded rotavirus vaccination programme (Rotarix, RV1), with vaccine doses scheduled for 2 and 4 months of age. Vaccination was restricted so that infants were only allowed to receive first dose between 6 and 20 weeks of age, and second dose before eight calendar months of age. We assessed the coverage and schedule non-compliance of rotavirus vaccination for babies born between June 2015 and August 2016, that is, since the inception of the publicly funded rotavirus vaccination programme, and determined factors associated with rotavirus vaccine uptake. DESIGN: Retrospective cohort study using linked administrative health data. SETTING: Alberta, Canada. PARTICIPANTS: Cohort of 66 689 children. PRIMARY AND SECONDARY OUTCOME MEASURES: (1) First and second dose rotavirus vaccination coverage, (2) percent of children non-compliant with recommended vaccine schedule and (3) adjusted ORs for factors associated with vaccination status. RESULTS: For the 66 689 children included in the study, coverage levels for one-dose and two-dose rotavirus vaccination were 87% and 83%, respectively. In comparison, two-dose diphtheria-tetanus-pertussis-polio-Haemophilus influenzae type b vaccine coverage was 92%, despite having the same dosing schedule. Schedule non-compliance during the publicly funded programme was very low. We observed socioeconomic disparities in the uptake of the vaccine, with income, location of residence and number of children in the household all contributing to the odds of a child being vaccinated with rotavirus. CONCLUSIONS: Compliance to the recommended rotavirus schedule was very high, suggesting that even with the restrictive rotavirus vaccine schedule, the vaccine can be delivered on-time. However, rotavirus vaccine coverage remained lower than DTaP, a similarly scheduled childhood vaccination. We also observed socioeconomic disparities in vaccine uptake. These findings raise concerns about rotavirus protection in the groups at highest risk for gastrointestinal illness, including low-income and rural populations.