Assessing the macroeconomic impact of a healthcare problem: the application of computable general equilibrium analysis to antimicrobial resistance

Microbial Isolates and Antimicrobial Resistance Patterns in Adults with Inborn Errors of Immunity: A Retrospective Longitudinal Analysis of Sputum Cultures

INTRODUCTION

Individuals with inborn errors of immunity (IEI) are at increased risk of respiratory infection and frequently receive prolonged broad-spectrum antibiotics, leading to antibiotic resistance. The aim of this study was to identify respiratory pathogens and antibiotic resistance patterns in IEI patients.

METHODS

We retrospectively studied 36 IEI patients with positive bacterial growth in sputum cultures between 2014 and 2023. Data covered hospitalizations, respiratory infections, yearly antibiotic prescriptions, past sputum cultures, and antibiotic sensitivities. Patients with primary ciliary dyskinesia (PCD) and bronchiectasis served as a control group.

RESULTS

A total of 314 sputum cultures were analyzed from patients with IEI, alongside 585 cultures from individuals with PCD and 113 cultures from patients with bronchiectasis. Patients with IEI had a median age of 23.5 years, with 61% male participants. The study compared the differences in bacterial isolates from sputum cultures and antibiotic resistance between patients with IEI and the control groups. The most common bacterial isolates across all groups were Haemophilus influenzae (159 isolates in IEI vs. 314 in PCD and 26 in bronchiectasis), Pseudomonas aeruginosa, and Streptococcus pneumoniae. In IEI patients, 992 symptomatic respiratory exacerbations and 43 pneumonia-related hospitalizations were recorded. Notably, H. influenzae in IEI patients showed high resistance rates to cefuroxime (82%), amoxicillin/clavulanic acid (66%), trimethoprim/sulfamethoxazole (59%), and ampicillin/sulbactam (49%). P. aeruginosa in IEI patients displayed significant resistance to ciprofloxacin (85%), ceftazidime (42%), and aminoglycosides (23-33%). Additionally, all S. pneumoniae isolates in IEI patients were tetracycline resistant, with high resistance rates to penicillin, clindamycin, and erythromycin. It is essential to highlight the substantial resistance of common pathogens to oral antibiotics. In contrast, the control groups exhibited lower resistance rates across all bacterial isolates.

CONCLUSION

Antimicrobial resistance is a growing concern among vulnerable IEI patients. We suggest conducting similar investigations in other regions to address this issue. The findings should inform future infection management guidelines for IEIs.

Capturing the Value of Vaccination within Health Technology Assessment and Health Economics-Practical Considerations for Expanding Valuation by Including Key Concepts

Following the development of a value of vaccination (VoV) framework for health technology assessment/cost-effectiveness analysis (HTA/CEA), and identification of three vaccination benefits for near-term inclusion in HTA/CEA, this final paper provides decision makers with methods and examples to consider benefits of health systems strengthening (HSS), equity, and macroeconomic gains. Expert working groups, targeted literature reviews, and case studies were used. Opportunity cost methods were applied for HSS benefits of rotavirus vaccination. Vaccination, with HSS benefits included, reduced the incremental cost-effectiveness ratio (ICER) by 1.4-50.5% (to GBP 11,552-GBP 23,016) depending on alternative conditions considered. Distributional CEA was applied for health equity benefits of meningococcal vaccination. Nearly 80% of prevented cases were among the three most deprived groups. Vaccination, with equity benefits included, reduced the ICER by 22-56% (to GBP 7014-GBP 12,460), depending on equity parameters. Macroeconomic models may inform HTA deliberative processes (e.g., disease impact on the labour force and the wider economy), or macroeconomic outcomes may be assessed for individuals in CEAs (e.g., impact on non-health consumption, leisure time, and income). These case studies show how to assess broader vaccination benefits in current HTA/CEA, providing decision makers with more accurate and complete VoV assessments. More work is needed to refine inputs and methods, especially for macroeconomic gains.

Economic impact of government health expenditure: An application of the computable general equilibrium model to the Iran

BACKGROUND

Considering the increase in health expenses and the government's role in health financing, this study investigated the economic impact of increases in the share of the health sector in the government budget while taxes remain unchanged and government spending is fixed.

MATERIAL AND METHODS

The economic model used in this study was a macroeconomic Computable General Equilibrium (CGE) model. This model was calibrated using a 2011 Social Accounting Matrix (SAM) Of Iran. The CGE model was solved with non-linear programming using the General Algebraic Modeling System package, version 2.50. The effect of this simulation on the government budget deficit, the production of different sectors of the economy, and the employment rate was investigated.

RESULTS

Based on our fundings the elasticity of substitution in the agricultural and industrial sectors is higher than in the health and service sector. Also, the biggest decrease in production occurred in the industry, agriculture, and service sectors, respectively. With the doubling of the share of government spending in the health sector, the employment rate of this sector has increased by 40.9%, but the highest decrease in the ignition rate is related to the service sectors (-2.7%), agriculture (-0.23%), and industry (-0.14%).

CONCLUSION

Increasing the share of government spending in the health sector in comparison with other sectors of the economy, provided that government spending is maintained in general, leads to a decrease in production and economic welfare. It seems that the Iranian government should seek to increase the sources of health financing and the share of government expenditures in the health sector with other ways in order to improve the health level of the society and have a positive effect on other economic sectors.

Emerging challenges in antimicrobial resistance: implications for pathogenic microorganisms, novel antibiotics, and their impact on sustainability

Overuse of antibiotics is accelerating the antimicrobial resistance among pathogenic microbes which is a growing public health challenge at the global level. Higher resistance causes severe infections, high complications, longer stays at hospitals and even increased mortality rates. Antimicrobial resistance (AMR) has a significant impact on national economies and their health systems, as it affects the productivity of patients or caregivers due to prolonged hospital stays with high economic costs. The main factor of AMR includes improper and excessive use of antimicrobials; lack of access to clean water, sanitation, and hygiene for humans and animals; poor infection prevention and control measures in hospitals; poor access to medicines and vaccines; lack of awareness and knowledge; and irregularities with legislation. AMR represents a global public health problem, for which epidemiological surveillance systems have been established, aiming to promote collaborations directed at the well-being of human and animal health and the balance of the ecosystem. MDR bacteria such as E. coli, Staphylococcus aureus, Pseudomonas aeruginosa, Enterococcus spp., Acinetobacter spp., and Klebsiella pneumonia can even cause death. These microorganisms use a variety of antibiotic resistance mechanisms, such as the development of drug-deactivating targets, alterations in antibiotic targets, or a decrease in intracellular antibiotic concentration, to render themselves resistant to numerous antibiotics. In context, the United Nations issued the Sustainable Development Goals (SDGs) in 2015 to serve as a worldwide blueprint for a better, more equal, and more sustainable existence on our planet. The SDGs place antimicrobial resistance (AMR) in the context of global public health and socioeconomic issues; also, the continued growth of AMR may hinder the achievement of numerous SDGs. In this review, we discuss the role of environmental pollution in the rise of AMR, different mechanisms underlying the antibiotic resistance, the threats posed by pathogenic microbes, novel antibiotics, strategies such as One Health to combat AMR, and the impact of resistance on sustainability and sustainable development goals.

Capturing Value Attributes in the Economic Evaluation of Ceftazidime with Avibactam for Treating Severe Aerobic Gram-Negative Bacterial Infections in the United Kingdom

INTRODUCTION

Antimicrobial resistance remains a serious and growing threat to public health, both globally and in the UK, leading to diminishing effectiveness of antimicrobials. Despite a clear need for new antimicrobials, the clinical pipeline is insufficient, driven by high research and development costs and limited expected returns on investment. To counteract this, National Institute for Health and Care Excellence (NICE) and National Health Service (NHS) England have launched a reimbursement mechanism, de-linked from volume of sales, that aims to reduce economic risk by recognising the broader population-level value of antimicrobials. The objective of this study was to quantify the value of ceftazidime-avibactam for treating gram-negative infections in the UK considering some of these broader value elements unique to antimicrobials.

METHODS

A previously developed dynamic disease transmission and cost-effectiveness model was applied to assess the value of introducing ceftazidime-avibactam to UK treatment practice in the management of gram-negative hospital-acquired infections in line with the licenced indications for ceftazidime-avibactam. Model inputs were parameterised using sources aligned to the UK perspective.

RESULTS

The introduction of ceftazidime-avibactam into a two-line treatment sequence saved over 2300 lives, leading to a gain of 27,600 life years and 22,000 quality-adjusted life years (QALY) at an additional cost of £17 million, over a ten-year transmission period. Ceftazidime-avibactam was associated with a net monetary benefit of £642 million at willingness to pay threshold of £30,000 per QALY; even at a lower threshold of £20,000 per QALY, the net monetary benefit is £422 million.

DISCUSSION

Increasing the diversity of antimicrobial treatments through the introduction of an additional antimicrobial, in this instance ceftazidime-avibactam, was associated with substantial clinical and economic benefits, when considering broader population-level value. Despite revealing considerable benefits, the value of ceftazidime-avibactam is only partially reflected in this analysis. Further efforts are required to fully operationalise the spectrum, transmission, enablement, diversity and insurance (STEDI) value framework and accurately reflect the population-level value of antimicrobials.

The potential impact of novel tuberculosis vaccine introduction on economic growth in low- and middle-income countries: A modeling study

BACKGROUND

Most individuals developing tuberculosis (TB) are working age adults living in low- and middle-income countries (LMICs). The resulting disability and death impact economic productivity and burden health systems. New TB vaccine products may reduce this burden. In this study, we estimated the impact of introducing novel TB vaccines on gross domestic product (GDP) growth in 105 LMICs.

METHODS AND FINDINGS

We adapted an existing macroeconomic model to simulate country-level GDP trends between 2020 and 2080, comparing scenarios for introduction of hypothetical infant and adolescent/adult vaccines to a no-new-vaccine counterfactual. We parameterized each scenario using estimates of TB-related mortality, morbidity, and healthcare spending from linked epidemiological and costing models. We assumed vaccines would be introduced between 2028 and 2047 and estimated incremental changes in GDP within each country from introduction to 2080, in 2020 US dollars. We tested the robustness of results to alternative analytic specifications. Both vaccine scenarios produced greater cumulative GDP in the modeled countries over the study period, equivalent to $1.6 (95% uncertainty interval: $0.8, 3.0) trillion for the adolescent/adult vaccine and $0.2 ($0.1, 0.4) trillion for the infant vaccine. These GDP gains were substantially lagged relative to the time of vaccine introduction, particularly for the infant vaccine. GDP gains resulting from vaccine introduction were concentrated in countries with higher current TB incidence and earlier vaccine introduction. Results were sensitive to secular trends in GDP growth but relatively robust to other analytic assumptions. Uncertain projections of GDP could alter these projections and affect the conclusions drawn by this analysis.

CONCLUSIONS

Under a range of assumptions, introducing novel TB vaccines would increase economic growth in LMICs.

V for vaccines and variants

In the context of the Covid-19 pandemic, we evaluate the effects of vaccines and virus variants on epidemiological and macroeconomic outcomes by means of Monte Carlo simulations of a macroeconomic-epidemiological agent-based model calibrated using data from the Lombardy region of Italy. From simulations we infer that vaccination plays the role of a mitigating factor, reducing the frequency and the amplitude of contagion waves and significantly improving macroeconomic performance with respect to a scenario without vaccination. The emergence of a variant, on the other hand, plays the role of an accelerating factor, leading to a deterioration of both epidemiological and macroeconomic outcomes and partly negating the beneficial impacts of the vaccine. A new and improved vaccine in turn can redress the situation. Vaccinations and variants, therefore, can be conceived of as drivers of an intertwined cycle impacting both epidemiological and macroeconomic developments.

Partially different? The importance of general equilibrium in health economic evaluations: An application to nocturia

Both the human capital approach and the friction cost approach are frequently used to quantify the productivity costs associated with illness, disability or death in health economic evaluations. In this paper we argue that these approaches have one major, but common shortcoming: they only capture partial equilibrium (PE) effects and therefore underestimate the true potential productivity costs associated with health conditions. They neglect the sizable, indirect, ripple effects in the economy captured by general equilibrium (GE) models. To demonstrate our point, we compare a traditional PE with a GE approach for the application to nocturia, a condition characterized by the need to frequently wake up at night to urinate. Nocturia is associated with substantial impairment of daytime functioning and work productivity. We employ large-scale United Kingdom (UK) employer-employee survey data to estimate the prevalence and productivity loss. These estimates are then used as shared inputs to drive both approaches. We find that the traditional PE approach underestimates the annual productivity cost of clinically relevant nocturia by around 16%. We propose a generalized GE/PE multiplier to approximate the GE effect for other health conditions. Our findings stress the importance of accounting for sizable GE effects when conducting health economic evaluations.

QM/MM Simulations Reveal the Determinants of Carbapenemase Activity in Class A β-Lactamases

β-lactam antibiotic resistance in Gram-negative bacteria, primarily caused by β-lactamase enzymes that hydrolyze the β-lactam ring, has become a serious clinical problem. Carbapenems were formerly considered "last resort" antibiotics because they escaped breakdown by most β-lactamases, due to slow deacylation of the acyl-enzyme intermediate. However, an increasing number of Gram-negative bacteria now produce β-lactamases with carbapenemase activity: these efficiently hydrolyze the carbapenem β-lactam ring, severely limiting the treatment of some bacterial infections. Here, we use quantum mechanics/molecular mechanics (QM/MM) simulations of the deacylation reactions of acyl-enzyme complexes of eight β-lactamases of class A (the most widely distributed β-lactamase group) with the carbapenem meropenem to investigate differences between those inhibited by carbapenems (TEM-1, SHV-1, BlaC, and CTX-M-16) and those that hydrolyze them (SFC-1, KPC-2, NMC-A, and SME-1). QM/MM molecular dynamics simulations confirm the two enzyme groups to differ in the preferred acyl-enzyme orientation: carbapenem-inhibited enzymes favor hydrogen bonding of the carbapenem hydroxyethyl group to deacylating water (DW). QM/MM simulations of deacylation give activation free energies in good agreement with experimental hydrolysis rates, correctly distinguishing carbapenemases. For the carbapenem-inhibited enzymes, free energies for deacylation are significantly higher than for the carbapenemases, even when the hydroxyethyl group was restrained to prevent interaction with the DW. Analysis of these simulations, and additional simulations of mutant enzymes, shows how factors including the hydroxyethyl orientation, the active site volume, and architecture (conformations of Asn170 and Asn132; organization of the oxyanion hole; and the Cys69-Cys238 disulfide bond) collectively determine catalytic efficiency toward carbapenems.

COVID-19 outbreak and sectoral performance of the Australian stock market: An event study analysis

The outbreak of COVID-19 has weakened the economy of Australia and its capital market since early 2020. The overall stock market has declined. However, some sectors become highly vulnerable while others continue to perform well even in the crisis period. Given this new reality, we seek to investigate the initial volatility and the sectoral return. In this study, we analyse data for eight sectors such as, transportation, pharmaceuticals, healthcare, energy, food, real estate, telecommunications and technology of the Australian stock market. In doing so, we obtain data from Australian Securities Exchange (ASX) and analysed them based on 'Event Study' method. Here, we use the 10-days window for the event of official announcement of the COVID-19 outbreak in Australia on 27 February 2020. The findings of the study show that on the day of announcement, the indices for food, pharmaceuticals and healthcare exhibit impressive positive returns. Following the announcement, the telecommunications, pharmaceuticals and healthcare sectors exhibit good performance, while poor performance is demonstrated by the transportation industry. The findings are vital for investors, market participants, companies, private and public policymakers and governments to develop recovery action plans for vulnerable sectors and enable investors to regain their confidence to make better investment decisions.

Quantitatively evaluating the cross-sectoral and One Health impact of interventions: A scoping review and case study of antimicrobial resistance

BACKGROUND

Current frameworks evaluating One Health (OH) interventions focus on intervention-design and -implementation. Cross-sectoral impact evaluations are needed to more effectively tackle OH-issues, such as antimicrobial resistance (AMR). We aimed to describe quantitative evaluation methods for interventions related to OH and cross-sectoral issues, to propose an explicit approach for evaluating such interventions, and to apply this approach to AMR.

METHODS

A scoping review was performed using WebofScience, EconLit, PubMed and gray literature. Quantitative evaluations of interventions that had an impact across two or more of the human, animal and environment sectors were included. Information on the interventions, methods and outcome measures found was narratively summarised. The information from this review informed the construction of a new approach to OH-related intervention evaluation, which then was applied to the field of AMR.

RESULTS

The review included 90 studies: 73 individual evaluations (from 72 papers) and 18 reviews, with a range of statistical modelling (n = 13 studies), mathematical modelling (n = 53) and index-creation/preference-ranking (n = 14) methods discussed. The literature highlighted the need to (I) establish stakeholder objectives, (II) establish quantifiable outcomes that feed into those objectives, (III) establish agents and compartments that affect these outcomes and (IV) select appropriate methods (described in this review) accordingly. Based on this, an evaluation model for AMR was conceptualised; a decision-tree of intervention options, a compartmental-microeconomic model across sectors and a general-equilibrium (macroeconomic) model are linked. The outcomes of this multi-level model (including cost-utility and Gross Domestic Product impact) can then feed into multi-criteria-decision analyses that weigh respective impact estimates alongside other chosen outcome estimates (for example equity or uncertainty).

CONCLUSION

In conclusion, stakeholder objectives are key in establishing which evaluation methods (and associated outcome measures) should be used for OH-related interventions. The stated multi-level approach also allows for sub-systems to be modelled in succession, where resources are constrained.

How Should the World Pay for a Coronavirus Disease (COVID-19) Vaccine?

The potential health and economic value of a vaccine for coronavirus disease (COVID-19) is self-evident given nearly 2 million deaths, "collateral" loss of life as other conditions go untreated, and massive economic damage. Results from the first licensed products are very encouraging; however, there are important reasons why we will likely need second and third generation vaccines. Dedicated incentives and funding focused explicitly on nurturing and advancing competing second and third generation vaccines are essential. This article proposes a collaborative, market-based financing mechanism for the world to incentivize and pay for the development of, and provide equitable access to, second and third generation COVID-19 vaccines. Specifically, we propose consideration of a Benefit-Based Advance Market Commitment (BBAMC). The BBAMC uses health technology assessment to determine value-based prices to guarantee overall market revenues, not revenue for any specific product or company. The poorest countries would not pay a value-based price but a discounted "tail-price." Innovators must agree to supply them at this tail price or to facilitate technology transfer to local licensees at low or zero cost to enable them to supply at this price. We expect these purchases to be paid for in full or large part by global donors. The BBAMC therefore sets prices in relation to value, protects intellectual property rights, encourages competition, and ensures all populations get access to vaccines, subject to agreed priority allocation rules.

Explaining stock markets' performance during the COVID‐19 crisis: Could Google searches be a significant behavioral indicator?

The purpose of this study is to examine the impact of the pandemic on the performance of stock markets, focusing on the behavioral influence of the fear due to COVID‐19. Using a data set of 10 developed countries during the period December 31, 2019, to September 30, 2020, we examine the impact of COVID‐19 on the performance of the stock markets. We incorporate the impact of the COVID‐19 pandemic using the following variables: (a) the number of new COVID‐19 cases, which was widely used as the main explanatory variable for market performance in early financial studies, and (b) a Google Search index, which collects the number of Google searches related to COVID‐19 and incorporates the health risk and the fear of COVID‐19 (the higher the number of searches for Covid terms, the higher the index value, and the higher the fear index). We employ our input into an EGARCH(1,1,1) model, and the findings show that the Google Search index enables us to draw statistically significant information regarding the impact of the COVID‐19 fear on the performance of the stock markets. On the other hand, the variable of the number of new COVID‐19 cases does not have any statistically significant influence on the performance of the stock markets. Google searches could be a useful tool for supporters of behavioral finance, scholars, and practitioners.

Economic Evaluation of Vaccines: Belgian Reflections on the Need for a Broader Perspective

OBJECTIVES

The standard framework of economic evaluation of health programs, which is increasingly used for policy funding decisions, is insufficiently equipped to reflect the full range of health and economic benefits conferred by vaccines and thus undervalues vaccination.

METHODS

In 2019, a group of Belgian health economic and clinical experts, supported by 2 senior international vaccination experts (1 American, 1 Belgian), convened 4 roundtable meetings to highlight which particular value elements of vaccination remain neglected in economic evaluations.

RESULTS

They concluded that the standard economic evaluation framework fails to reflect the full value of vaccination with respect to prevention of complications linked to some vaccine-preventable diseases, health gains for caregivers, herd effects, changes in exposure to and distribution of serotypes, the effect on antimicrobial resistance, productivity gains for caregivers and patients, and the distributive implications of vaccination programs.

CONCLUSIONS

Here, suggestions are made regarding how these shortcomings can be addressed in future economic evaluations of vaccines and how a more level playing field between vaccines and other health programs can be created.

Estimating the global economic benefits of physically active populations over 30 years (2020-2050)

OBJECTIVES

We assess the potential benefits of increased physical activity for the global economy for 23 countries and the rest of the world from 2020 to 2050. The main factors taken into account in the economic assessment are excess mortality and lower productivity.

METHODS

This study links three methodologies. First, we estimate the association between physical inactivity and workplace productivity using multivariable regression models with proprietary data on 120 143 individuals in the UK and six Asian countries (Australia, Malaysia, Hong Kong, Thailand, Singapore and Sri Lanka). Second, we analyse the association between physical activity and mortality risk through a meta-regression analysis with data from 74 prior studies with global coverage. Finally, the estimated effects are combined in a computable general equilibrium macroeconomic model to project the economic benefits of physical activity over time.

RESULTS

Doing at least 150 min of moderate-intensity physical activity per week, as per lower limit of the range recommended by the 2020 WHO guidelines, would lead to an increase in global gross domestic product (GDP) of 0.15%-0.24% per year by 2050, worth up to US$314-446 billion per year and US$6.0-8.6 trillion cumulatively over the 30-year projection horizon (in 2019 prices). The results vary by country due to differences in baseline levels of physical activity and GDP per capita.

CONCLUSIONS

Increasing physical activity in the population would lead to reduction in working-age mortality and morbidity and an increase in productivity, particularly through lower presenteeism, leading to substantial economic gains for the global economy.

The Mechanisms and the Applications of Antibacterial Polymers in Surface Modification on Medical Devices

Medical device contamination caused by microbial pathogens such as bacteria and fungi has posed a severe threat to the patients' health in hospitals. Due to the increasing resistance of pathogens to antibiotics, the efficacy of traditional antibiotics treatment is gradually decreasing for the infection treatment. Therefore, it is urgent to develop new antibacterial drugs to meet clinical or civilian needs. Antibacterial polymers have attracted the interests of researchers due to their unique bactericidal mechanism and excellent antibacterial effect. This article reviews the mechanism and advantages of antimicrobial polymers and the consideration for their translation. Their applications and advances in medical device surface coating were also reviewed. The information will provide a valuable reference to design and develop antibacterial devices that are resistant to pathogenic infections.

Inadequacies in Hospital Waste and Sewerage Management in Chattogram, Bangladesh: Exploring Environmental and Occupational Health Hazards

Bangladesh has been grappling with the issues of improper hospital waste management. To reflect the inadequacies in existing management practices and the potential implications on the environment and health, this study evaluated the Knowledge, Attitude, and Practice (KAP) of doctors and nurses in a private and a public hospital in Chattogram city via a structured questionnaire survey. At the public hospital, 20.4% of the doctors and 6% of the nurses had occupational illnesses, compared to 36% of the doctors and 26.5% of the nurses at the private hospital. At the public hospital, 67.8% of the nurses wore PPE during waste collection, compared to 17.7% in the private hospital. Hospital wastes and occupational safety are not properly dealt with in both hospitals. An inadequacy was observed in the knowledge of hospital waste management among healthcare workers. The route of hospital wastes from the sources to the end destination was also traced via interviews and focus group discussions, which revealed that disposal practices of the hospital solid waste were environmentally unsustainable. In attempts to show opportunities for environmental and health risks from the hospital wastewater, this study also investigated the quality of the wastewater and tested it for the presence of resistant enteric pathogens. E. coli and S. aureus from both hospitals showed resistance against some common antibiotics used in Bangladesh. The physicochemical properties of the samples were nearly compliant with the Bangladesh Water Quality Standards for hospital wastewater. While more robust sampling and water quality analysis are required, this study provides basic water quality indicators and scope for future research to understand the apparent significant negative impact on the environment and health.

Quantifying the economic cost of antibiotic resistance and the impact of related interventions: rapid methodological review, conceptual framework and recommendations for future studies

BACKGROUND

Antibiotic resistance (ABR) poses a major threat to health and economic wellbeing worldwide. Reducing ABR will require government interventions to incentivise antibiotic development, prudent antibiotic use, infection control and deployment of partial substitutes such as rapid diagnostics and vaccines. The scale of such interventions needs to be calibrated to accurate and comprehensive estimates of the economic cost of ABR.

METHODS

A conceptual framework for estimating costs attributable to ABR was developed based on previous literature highlighting methodological shortcomings in the field and additional deductive epidemiological and economic reasoning. The framework was supplemented by a rapid methodological review.

RESULTS

The review identified 110 articles quantifying ABR costs. Most were based in high-income countries only (91/110), set in hospitals (95/110), used a healthcare provider or payer perspective (97/110), and used matched cohort approaches to compare costs of patients with antibiotic-resistant infections and antibiotic-susceptible infections (or no infection) (87/110). Better use of methods to correct biases and confounding when making this comparison is needed. Findings also need to be extended beyond their limitations in (1) time (projecting present costs into the future), (2) perspective (from the healthcare sector to entire societies and economies), (3) scope (from individuals to communities and ecosystems), and (4) space (from single sites to countries and the world). Analyses of the impact of interventions need to be extended to examine the impact of the intervention on ABR, rather than considering ABR as an exogeneous factor.

CONCLUSIONS

Quantifying the economic cost of resistance will require greater rigour and innovation in the use of existing methods to design studies that accurately collect relevant outcomes and further research into new techniques for capturing broader economic outcomes.

Health and economic burden of antimicrobial-resistant infections in Australian hospitals: a population-based model

OBJECTIVE

To estimate the additional health and economic burden of antimicrobial-resistant (AMR) infections in Australian hospitals.

METHODS

A simulation model based on existing evidence was developed to assess the additional mortality and costs of healthcare-associated AMR Escherichia coli (E. coli), Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecium, and Staphylococcus aureus infections.

SETTING

Australian public hospitals.

FINDINGS

Australian hospitals spent an additional AUD$5.8 million (95% uncertainty interval [UI], $2.2-$11.2 million) per year treating ceftriaxone-resistant E.coli bloodstream infections (BSI), and an estimated AUD$5.5 million per year (95% UI, $339,633-$22.7 million) treating MRSA patients. There are no reliable estimates of excess morbidity and mortality from AMR infections in sites other than the blood and in particular for highly prevalent AMR E. coli causing urinary tract infections (UTIs).

CONCLUSION

The limited evidence-base of the health impact of resistant infection in UTIs limits economic studies estimating the overall burden of AMR. Such data are increasingly important and are urgently needed to support local clinical practice as well as national and global efforts to curb the spread of AMR.

Exploring the Use of a General Equilibrium Method to Assess the Value of a Malaria Vaccine: An Application to Ghana

Background. Malaria is an important health and economic burden in sub-Saharan Africa. Conventional economic evaluations typically consider only direct costs to the health care system and government budgets. This paper quantifies the potential impact of malaria vaccination on the wider economy, using Ghana as an example. Methods. We used a computable general equilibrium model of the Ghanaian economy to estimate the macroeconomic impact of malaria vaccination in children under the age of 5, with a vaccine efficacy of 50% against clinical malaria and 20% against malaria mortality. The model considered changes in demography and labor productivity, and projected gross domestic product (GDP) over a time frame of 30 years. Vaccine coverage ranging from 20% to 100% was compared with a baseline with no vaccination. Results. Malaria vaccination with 100% coverage was projected to increase the GDP of Ghana over 30 years by US$6.93 billion (in 2015 prices) above the baseline without vaccination, equivalent to an increase in annual GDP growth of 0.5%. Projected GDP per capita would increase in the first year due to immediate reductions in time lost from work by adults caring for children with malaria, then decrease for several years as reductions in child mortality increase the number of dependent children, then show a sustained increase after Year 11 due to long-term productivity improvements in adults resulting from fewer malaria episodes in childhood. Conclusion. Investing in improving childhood health by vaccinating against malaria could result in substantial long-term macroeconomic benefits when these children enter the workforce as adults. These macroeconomic benefits are not captured by conventional economic evaluations and constitute an important potential benefit of vaccination.

Antimicrobial Resistance in the Asia Pacific region: a meeting report

The Asia Pacific region, home to two-thirds of the world's population and ten of the least developed countries, is considered a regional hot-spot for the emergence and spread of antimicrobial resistance (AMR). Despite this, there is a dearth of high-quality regional data on the extent of AMR. Recognising the urgency to close this gap, Singapore organised a meeting to discuss the problems in the region and frame a call for action. Representatives from across the region and beyond attended the meeting on the "Antimicrobial Resistance in the Asia Pacific & its impact on Singapore" held in November 2018. This meeting report is a summary of the discussions on the challenges and progress in surveillance, drivers and levers of AMR emergence, and the promising innovations and technologies that could be used to combat the increasing threat of AMR in the region. Enhanced surveillance and research to provide improved evidence-based strategies and policies are needed. The major themes that emerged for an action plan are working towards a tailored solution for the region by harnessing the One Health approach, enhancing inter-country collaborations, and collaboratively leverage upon new emerging technologies. A regionally coordinated effort that is target-driven, sustainable and builds on a framework facilitating communication and governance will strengthen the fight against AMR in the Asia Pacific region.

Estimating the money flow in the economy attributed to rotavirus disease and vaccination in the Netherlands using a Social Accounting Matrix (SAM) framework

Background: The economics of rotavirus gastroenteritis in infants <5 years old is well-known within healthcare. The financial consequences for families, employers and authorities are not so well explored. The present study evaluates how vaccine prevention changes money flows among those involved in the management of disease, and its consequences. Methods: A Social Accounting Matrix (SAM) framework has been developed reflecting the distribution of income and spending at equilibrium affected by rotavirus disease among all those concerned for 1 year. The data came from official sources and published literature. A comparison of the financial equilibrium between with and without a national rotavirus immunization program has been conducted, along with sensitivity analysis for the results. Results: The total financial cost difference at equilibrium between presence and absence of rotavirus vaccination was +€26.758 million over one year as a net economic surplus. The payment of vaccination (€19.194 million) by the government was offset by the increase in tax revenue (€14.561 million) and by the lower spending in treatment care (€7.998 million). Conclusion: Studying the financial flows between different transacting agents can demonstrate the financial burden of a disease and the benefits of its prevention on agents' income and spending.

Value of information analysis in telehealth for chronic heart failure management

OBJECTIVES

Value of information (VOI) analysis provides information on opportunity cost of a decision in healthcare by estimating the cost of reducing parametric uncertainty and quantifying the value of generating additional evidence. This study is an application of the VOI methodology to the problem of choosing between home telemonitoring and nurse telephone support over usual care in chronic heart failure management in the Netherlands.

METHODS

The expected value of perfect information (EVPI) and the expected value of partially perfect information (EVPPI) analyses were based on an informal threshold of €20K per quality-adjusted life-year. These VOI-analyses were applied to a probabilistic Markov model comparing the 20-year costs and effects in three interventions. The EVPPI explored the value of decision uncertainty caused by the following group of parameters: treatment-specific transition probabilities between New York Heart Association (NYHA) defined disease states, utilities associated with the disease states, number of hospitalizations and ER visits, health state specific costs, and the distribution of patients per NYHA group. We performed the analysis for two population sizes in the Netherlands-patients in all NYHA classes of severity, and patients in NYHA IV class only.

RESULTS

The population EVPI for an effective population of 2,841,567 CHF patients in All NYHA classes of severity over the next 20 years is more than €4.5B, implying that further research is highly cost-effective. In the NYHA IV only analysis, for the effective population of 208,003 patients over next 20 years, the population EVPI at the same informal threshold is approx. €590M. The EVPPI analysis showed that the only relevant group of parameters that contribute to the overall decision uncertainty are transition probabilities, in both All NYHA and NYHA IV analyses.

CONCLUSIONS

Results of our VOI exercise show that the cost of uncertainty regarding the decision on reimbursement of telehealth interventions for chronic heart failure patients is high in the Netherlands, and that future research is needed, mainly on the transition probabilities.

The challenge of antimicrobial resistance: What economics can contribute

As antibiotic consumption grows, bacteria are becoming increasingly resistant to treatment. Antibiotic resistance undermines much of modern health care, which relies on access to effective antibiotics to prevent and treat infections associated with routine medical procedures. The resulting challenges have much in common with those posed by climate change, which economists have responded to with research that has informed and shaped public policy. Drawing on economic concepts such as externalities and the principal–agent relationship, we suggest how economics can help to solve the challenges arising from increasing resistance to antibiotics. We discuss solutions to the key economic issues, from incentivizing the development of effective new antibiotics to improving antibiotic stewardship through financial mechanisms and regulation.

Using the best available data to estimate the cost of antimicrobial resistance: a systematic review

Background

Valuation of the economic cost of antimicrobial resistance (AMR) is important for decision making and should be estimated accurately. Highly variable or erroneous estimates may alarm policy makers and hospital administrators to act, but they also create confusion as to what the most reliable estimates are and how these should be assessed. This study aimed to assess the quality of methods used in studies that quantify the costs of AMR and to determine the best available evidence of the incremental cost of these infections.

Methods

In this systematic review, we searched PubMed, Embase, Cinahl, Cochrane databases and grey literature sources published between January 2012 and October 2016. Articles reporting the additional burden of Enterococcus spp., Escherichia coli (E. coli), Klebsiella pneumoniae (K. pneumoniae), Pseudomonas aeruginosa (P. aeruginosa) and Staphylococcus aureus (S. aureus) resistant versus susceptible infections were sourced. The included studies were broadly classified as reporting oncosts from the healthcare/hospital/hospital charges perspective or societal perspective. Risk of bias was assessed based on three methodological components: (1) adjustment for length of stay prior to infection onset and consideration of time-dependent bias, (2) adjustment for comorbidities or severity of disease, and (3) adjustment for inappropriate antibiotic therapy.

Results

Of 1094 identified studies, we identified 12 peer-reviewed articles and two reports that quantified the economic burden of clinically important resistant infections. Two studies used multi-state modelling to account for the timing of infection minimising the risk of time dependent bias and these were considered to generate the best available cost estimates. Studies report an additional CHF 9473 per extended-spectrum beta-lactamases -resistant Enterobacteriaceae bloodstream infections (BSI); additional €3200 per third-generation cephalosporin resistant Enterobacteriaceae BSI; and additional €1600 per methicillin-resistant S. aureus (MRSA) BSI. The remaining studies either partially adjusted or did not consider the timing of infection in their analysis.

Conclusions

Implementation of AMR policy and decision-making should be guided only by reliable, unbiased estimates of effect size. Generating these estimates requires a thorough understanding of important biases and their impact on measured outcomes. This will ensure that researchers, clinicians, and other key decision makers concerned with increasing public health threat of AMR are accurately guided by the best available evidence.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0472-z) contains supplementary material, which is available to authorized users.

Ebola crisis response in the USA: Communication management and SOPs

This research focuses on the 2014 Ebola crisis response by emergency managers in the Dallas-Fort Worth (DFW) Metropolitan region in the State of Texas, U.S.A. It examines the patterns of crisis communication and the use of Standard Operating Procedures (SOPs) during the first month of the crisis. Primary data collected from 24 face-to-face interviews and 12 online surveys are analyzed. The research identifies elements contributing to organizational failures, which by their very nature gain public and media attention, and also explicates the less mentioned successful decisions made by response agencies in the DFW region. It is important to investigate both failures and successes to help inform organizational learning for better preparedness to future health crises. Findings suggest that, although there was a breakdown in communication between small city governments/ municipalities and higher levels of government at the State and Federal levels, prior training and collaborative relationships helped in improvised decision-making. Takeaways for practitioners include reiterating the importance of establishing SOPs, merits of flexibility, and improvisational decisions for shared learning.

Clinical management of drug-resistant bacteria in Australian hospitals: An online survey of doctors' opinions

BACKGROUND

To gain a better understanding of clinical practice for the treatment of common drug-resistant infections.

METHODS

A web-based anonymous survey was developed to gain a better understanding of clinical practice of patients infected with drug-resistant bloodstream infections (BSI). The survey instrument was a questionnaire requesting doctors to provide their opinion on the most likely choice of an antibiotic, dose and route of administration for patients infected with a drug-resistant Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa or Enterococcus faecium.

RESULTS

All of the survey participants (n = 28) were hospital-based doctors. Choice of therapy for drug-resistant E. coli and K. pneumoniae was uniform across survey participants. However, optimal treatment of ceftazidime-resistant P. aeruginosa and VRE was less clear.

CONCLUSION

The survey adds to the limited body of evidence in this clinical area and can be a useful tool for health economists in determining the additional cost of treating patients with drug-resistant infections.

The welfare implications of public healthcare financing: a macro-micro simulation analysis of Uganda

Studies on global health and development suggest that there is a strong correlation between the burden of disease and a country's level of income. Poorer countries tend to suffer more deaths from preventable causes such as communicable, maternal, perinatal and nutritional conditions, compared with high-income countries. In low-income countries, the government health expenditure share in the general government budget is low and out-of-pocket payments for healthcare relatively high. They also rely heavily on external resources for health funding, yet sustainability of external resource flows is not guaranteed. This article explores increasing public healthcare funding from domestic resources mobilization, and evaluates the impact of measures to achieve this on sectoral growth and poverty reduction rates in Uganda using a dynamic computable general equilibrium model. This article shows that increasing the government health budget share, facilitates expanded healthcare services, improved population health, higher sectoral growth and reduced poverty. The agricultural sector is predicted to post the highest growth when compared with services and industry sectors under both domestic taxation and aid funding scenarios, while national poverty is predicted to decline from 31 to 12% of the population by 2020. This article demonstrates that the most effective measure is to frontload investment in healthcare and generate additional domestic funding for health from a household tax earmarked for health.

Resistance Elasticity of Antibiotic Demand in Intensive Care

The emergence and spread of antimicrobial resistance (AMR) is still an unresolved problem worldwide. In intensive care units (ICUs), first-line antibiotic therapy is highly standardized and widely empiric while treatment failure because of AMR often has severe consequences. Simultaneously, there is a limited number of reserve antibiotics, whose prices and/or side effects are substantially higher than first-line therapy. This paper explores the implications of resistance-induced substitution effects in ICUs. The extent of such substitution effects is shown in a dynamic fixed effect regression analysis using a panel of 66 German ICUs with monthly antibiotic use and resistance data between 2001 and 2012. Our findings support the hypothesis that demand for reserve antibiotics substantially increases when resistance towards first-line agents rises. For some analyses the lagged effect of resistance is also significant, supporting the conjecture that part of the substitution effect is caused by physicians changing antibiotic choices in empiric treatment by adapting their resistance expectation to new information on resistance prevalence. The available information about resistance rates allows physicians to efficiently balance the trade-off between exacerbating resistance and ensuring treatment success. However, resistance-induced substitution effects are not free of charge. These effects should be considered an indirect burden of AMR. Copyright © 2016 John Wiley & Sons, Ltd.

Design and Implementation of a Telepediatric Primary-Level and Low-Cost System to Reduce Unnecessary Patient Transfers

BACKGROUND

Most inhabitants in Latin America are concentrated in large urban foci with different access to facilities. Although the main hospitals offer specialized services, economically vulnerable populations cannot easily afford these services, the pediatric population being most affected. This article presents the design and implementation of a low cost telepediatric system, applied to primary care hospitals through a study in Bogotá, Colombia, mainly aimed to reduce the number of unnecessary transfers commonly sent to specialized medical services.

MATERIALS AND METHODS

The system was carried out over 6 months with a higher incidence of acute respiratory illness in children between 0 and 5 years in nine primary care hospitals in Bogotá. Nineteen (n = 19) pediatricians were trained by a group of engineers that supports the system permanently. The reduction of patient transfers was compared with previous reports of the National Statistical Department in Colombia.

RESULTS

The system reduced both the number of patient transfers to higher level hospitals by 83% and the waiting times for patient transfer, improving healthcare in pediatric patients at a reasonable cost, affecting more than 700 patients. At the same time, a decrease of about 17% in the use of antibiotics was observed, which is an important current public health issue.

CONCLUSIONS

The use of telemedicine improves the efficiency of public health resources, even in big cities such as Bogotá, reducing the number of unnecessary patient transfers and the optimization and appropriate use of medicines.

Antimicrobial resistance-a threat to the world's sustainable development

This commentary examines how specific sustainable development goals (SDGs) are affected by antimicrobial resistance and suggests how the issue can be better integrated into international policy processes. Moving beyond the importance of effective antibiotics for the treatment of acute infections and health care generally, we discuss how antimicrobial resistance also impacts on environmental, social, and economic targets in the SDG framework. The paper stresses the need for greater international collaboration and accountability distribution, and suggests steps towards a broader engagement of countries and United Nations agencies to foster global intersectoral action on antimicrobial resistance.

Effects of selection pressure and genetic association on the relationship between antibiotic resistance and virulence in Escherichia coli

Antibiotic selection pressure and genetic associations may lead to the cooccurrence of resistance and virulence in individual pathogens. However, there is a lack of rigorous epidemiological evidence that demonstrates the cooccurrence of resistance and virulence at the population level. Using samples from a population-based case-control study in 25 villages in rural Ecuador, we characterized resistance to 12 antibiotics among pathogenic (n = 86) and commensal (n = 761) Escherichia coli isolates, classified by the presence or absence of known diarrheagenic virulence factor genes. The prevalences of resistance to single and multiple antibiotics were significantly higher for pathogenic isolates than for commensal isolates. Using a generalized estimating equation, antibiotic resistance was independently associated with virulence factor carriage, case status, and antibiotic use (for these respective factors: odds ratio [OR] = 3.0, with a 95% confidence interval [CI] of 1.7 to 5.1; OR = 2.0, with a 95% CI of 1.3 to 3.0; and OR = 1.5, with a 95% CI of 0.9 to 2.5). Virulence factor carriage was more strongly related to antibiotic resistance than antibiotic use for all antibiotics examined, with the exception of fluoroquinolones, gentamicin, and cefotaxime. This study provides epidemiological evidence that antibiotic resistance and virulence factor carriage are linked in E. coli populations in a community setting. Further, these data suggest that while the cooccurrence of resistance and virulence in E. coli is partially due to antibiotic selection pressure, it is also genetically determined. These findings should be considered in developing strategies for treating infections and controlling for antibiotic resistance.

Antibiotic resistance in patients with primary immunodeficiency disorders versus immunocompetent patients

OBJECTIVES

We aimed to investigate the antimicrobial susceptibility among bacterial isolates of patients with primary immunodeficiency disorders (PID) in comparison with immunocompetent patients.

METHODS

Patients' antibiotic sensitivity profiles were extracted from their medical records. In order to compare the antibiotic sensitivity profiles of PID patients with immunocompetent patients, the results of antibiograms of patients who did not have a known or suspected immunodeficiency and were hospitalized during the same period were obtained and used as control subjects.

RESULTS

A total number of 257 isolates were obtained from 86 PID patients. Antimicrobial susceptibilities of several organisms isolated from PID patients were significantly lower compared to that of immunocompetent patients.

CONCLUSION

Antibiotic resistance seems to be higher among PID patients compared to immunocompetent patients. This indicates a need for further investigations for the possible factors responsible for antibiotic resistance in PID patients.

Understanding and managing zoonotic risk in the new livestock industries

BACKGROUND

In many parts of the world, livestock production is undergoing a process of rapid intensification. The health implications of this development are uncertain. Intensification creates cheaper products, allowing more people to access animal-based foods. However, some practices associated with intensification may contribute to zoonotic disease emergence and spread: for example, the sustained use of antibiotics, concentration of animals in confined units, and long distances and frequent movement of livestock.

OBJECTIVES

Here we present the diverse range of ecological, biological, and socioeconomic factors likely to enhance or reduce zoonotic risk, and identify ways in which a comprehensive risk analysis may be conducted by using an interdisciplinary approach. We also offer a conceptual framework to guide systematic research on this problem.

DISCUSSION

We recommend that interdisciplinary work on zoonotic risk should take into account the complexity of risk environments, rather than limiting studies to simple linear causal relations between risk drivers and disease emergence and/or spread. In addition, interdisciplinary integration is needed at different levels of analysis, from the study of risk environments to the identification of policy options for risk management.

CONCLUSION

Given rapid changes in livestock production systems and their potential health implications at the local and global level, the problem we analyze here is of great importance for environmental health and development. Although we offer a systematic interdisciplinary approach to understand and address these implications, we recognize that further research is needed to clarify methodological and practical questions arising from the integration of the natural and social sciences.

Value of information analysis from a societal perspective: a case study in prevention of major depression

OBJECTIVES

Productivity losses usually have a considerable impact on cost-effectiveness estimates while their estimated values are often relatively uncertain. Therefore, parameters related to these indirect costs play a role in setting priorities for future research from a societal perspective. Until now, however, value of information analyses have usually applied a health care perspective for economic evaluations. Hence, the effect of productivity losses has rarely been investigated in such analyses. The aim of the current study therefore was to investigate the effects of including or excluding productivity costs in value of information analyses.

METHODS

Expected value of information analysis (EVPI) was performed in cost-effectiveness evaluation of prevention from both societal and health care perspectives, to give us the opportunity to compare different perspectives. Priorities for future research were determined by partial EVPI. The program to prevent major depression in patients with subthreshold depression was opportunistic screening followed by minimal contact psychotherapy.

RESULTS

The EVPI indicated that regardless of perspective, further research is potentially worthwhile. Partial EVPI results underlined the importance of productivity losses when a societal perspective was considered. Furthermore, priority setting for future research differed according to perspective.

CONCLUSIONS

The results illustrated that advise for future research will differ for a health care versus a societal perspective and hence the value of information analysis should be adjusted to the perspective that is relevant for the decision makers involved. The outcomes underlined the need for carefully choosing the suitable perspective for the decision problem at hand.

The impact of pricing and patent expiration on demand for pharmaceuticals: an examination of the use of broad-spectrum antimicrobials

The aim of the analysis was to determine whether demand in Germany for specific antimicrobial agents is driven by prices that drop considerably when generic substitutes become available. A time-series approach was therefore carried out to explore price elasticities of demand for two different classes of broad-spectrum antimicrobials (fluoroquinolones and cephalosporins) using data on ambulatory antibiotics prescribed on the German statutory health insurance scheme and data on in-hospital antibiotic use in a German teaching hospital. In short, we attempted to explain demand for different antibiotics based on changes in price and hospital-wide morbidity. The data indicate that patent expiration is followed by substantial decreases in the price of antibiotics. In the outpatient sector, all antibiotics included in the analysis showed significant negative own-price elasticities of demand. However, in the hospital settings, significant own-price elasticities were only determined for some antibiotics, although price decreases were stronger than in the outpatient sector. We conclude that price dependence of demand for antimicrobials is present both in the ambulatory and the hospital setting. However, this is especially surprising in the hospital setting because price differences among the antibiotics observed are particularly small compared with the overall cost of hospitalisation.

Economic consequences of the demography of MRSA patients and the impact of broad-spectrum antimicrobials

BACKGROUND

Studies have determined the societal impact of methicillin-resistant Staphylococcus aureus (MRSA) by modelling its impact on labour supply and productivity. In addition, most of the studies on the topic conclude that the problem of resistance should be counteracted on the macro level by reducing overall antibacterial consumption.

OBJECTIVE

Two major questions have been raised in the present work. Firstly, is MRSA impairing labour supply and productivity? Secondly, is it the overall use of antibacterials that may be seen as crucial to the spread of MRSA infections?

METHODS

The age distribution of MRSA patients is compared with the age distribution of the entire patient population at a German teaching hospital. In addition, the age distribution of MRSA patients was applied to the age distribution of the German population in the year 2050 in order to identify the effects of the double-ageing process on the spread of MRSA. Furthermore, recent epidemiological studies were reviewed on the impact of overall antibacterial consumption on MRSA infection rates.

RESULTS

Based on available data, we show that patients infected or colonized with MRSA are, for the most part, beyond retirement age and thus not responsible for changes in labour supply or productivity. Application of age distribution of MRSA patients to the age distribution of the German population in the year 2050 gives a 24% increase in the number of MRSA cases to a total of 182 778 due to an ageing population. In addition, we show that a 32% reduction in the cost of MRSA to the German healthcare system could be reached if use of fluoroquinolones and third-generation cephalosporins was reduced by just 10% and, correspondingly, use of antiseptics for hand disinfection was increased by 10%.

CONCLUSIONS

MRSA is a phenomenon that, to a larger degree, affects the elderly population rather than the labour force. When it comes to policy options to counteract MRSA on the macro level, most economic research on the topic is biased in assuming that the overall use of antibacterials is responsible for the spread of MRSA infections.

Economic implications of the dynamic relationship between antibiotic use and hospital-acquired infections

OBJECTIVES

The emergence and spread of antimicrobial resistance is still an unresolved problem worldwide. Recent evidence shows correlations between the volume of broad-spectrum antibiotics used in the hospital setting and the incidence of multidrug-resistant bacteria. According to this dynamic relationship, loss of antibiotic activity can be modeled as a negative externality of antibiotic consumption.

METHODS

The present study proposes to present an economic model describing the probability of antibiotic treatment failure as a function of antimicrobial use and alcohol-based hand-rub use. Furthermore, the results of recently conducted time-series analyses and cost-of-illness studies are applied to the model to determine the externalities of antibiotic consumption and alcohol-based hand-rub use with respect to the costs of hospital-acquired infections.

RESULTS

According to our calculations, the consumption of third-generation cephalosporins and fluoroquinolones is associated with the highest negative externalities (€143 and €101, respectively) because their use has been shown to be associated with most types of hospital-acquired infections. In contrast, the use of alcohol-based hand-rub solution for hand disinfection is associated with a positive externality of 41 cents per single disinfection of the hands.

CONCLUSIONS

The externalities presented in this work represent a possible application of cost-of-illness data to quantify the impact of antibiotic use on antimicrobial resistance. In addition, the results indicate that most economic research on the topic is biased in assuming the overall use of antibiotics to be responsible for the spread of antimicrobial resistance.

Antibiotic resistance in primary care in Austria - a systematic review of scientific and grey literature

Background

Antibiotic resistance is an increasing challenge for health care services worldwide. While up to 90% of antibiotics are being prescribed in the outpatient sector recommendations for the treatment of community-acquired infections are usually based on resistance findings from hospitalized patients. In context of the EU-project called "APRES - the appropriateness of prescribing antibiotic in primary health care in Europe with respect to antibiotic resistance" it was our aim to gain detailed information about the resistance data from Austria in both the scientific and the grey literature.

Methods

A systematic review was performed including scientific and grey literature published between 2000 and 2010. Inclusion and exclusion criteria were defined and the review process followed published recommendations.

Results

Seventeen scientific articles and 23 grey literature documents could be found. In contrast to the grey literature, the scientific publications describe only a small part of the resistance situation in the primary health care sector in Austria. Merely half of these publications contain data from the ambulatory sector exclusively but these data are older than ten years, are very heterogeneous concerning the observed time period, the number and origin of the isolates and the kind of bacteria analysed. The grey literature yields more comprehensive and up-to-date information of the content of interest. These sources are available in German only and are not easily accessible. The resistance situation described in the grey literature can be summarized as rather stable over the last two years. For Escherichia coli e.g. the highest antibiotic resistance rates can be seen with fluorochiniolones (19%) and trimethoprim/sulfamethoxazole (27%).

Conclusion

Comprehensive and up-to-date antibiotic resistance data of different pathogens isolated from the community level in Austria are presented. They could be found mainly in the grey literature, only few are published in peer-reviewed journals. The grey literature, therefore, is a very valuable source of relevant information. It could be speculated that the situation of published literature is similar in other countries as well.

Accounting for Methodological, Structural, and Parameter Uncertainty in Decision-Analytic Models

Accounting for uncertainty is now a standard part of decision-analytic modeling and is recommended by many health technology agencies and published guidelines. However, the scope of such analyses is often limited, even though techniques have been developed for presenting the effects of methodological, structural, and parameter uncertainty on model results. To help bring these techniques into mainstream use, the authors present a step-by-step guide that offers an integrated approach to account for different kinds of uncertainty in the same model, along with a checklist for assessing the way in which uncertainty has been incorporated. The guide also addresses special situations such as when a source of uncertainty is difficult to parameterize, resources are limited for an ideal exploration of uncertainty, or evidence to inform the model is not available or not reliable. Methods for identifying the sources of uncertainty that influence results most are also described. Besides guiding analysts, the guide and checklist may be useful to decision makers who need to assess how well uncertainty has been accounted for in a decision-analytic model before using the results to make a decision.

Estimating the economic impact of pandemic influenza: An application of the computable general equilibrium model to the U.K

There is concern regarding the impact that a global infectious disease pandemic might have, especially the economic impact in the current financial climate. However, preparedness planning concentrates more upon population health and maintaining a functioning health sector than on the wider economic impact. We developed a single country Computable General Equilibrium model to estimate the economic impact of pandemic influenza (PI) and associated policies. While the context for this development was the United Kingdom, there are lessons to be drawn for application of this methodology, as well as indicative results, to other contexts.

Disease scenarios were constructed from an epidemiological model which estimated case fatality rates (mild, moderate and severe) as 0.06%, 0.18% and 0.35%. A clinical attack rate of 35% was also used to produce influenza scenarios, together with preparedness policies, including antivirals and school closure, and the possible prophylactic absence of workers.

UK cost estimates (in Sterling) are presented, together with relative percentage impacts applicable to similar large economies. Percentage/cost estimates suggest PI would reduce GDP by 0.3% (£3.5bn), 0.4% (£5bn) and 0.6% (£7.4bn) respectively for the three disease scenarios. However, the impact of PI itself is smaller than disease mitigation policies: combining school closure with prophylactic absenteeism yields percentage/cost effects of 1.1% (£14.7bn), 1.3% (£16.3bn) and 1.4% (£18.5bn) respectively for the three scenarios. Sensitivity analysis shows little variability with changes in disease parameters but notable changes with variations in school closure and prophylactic absenteeism. The most severe sensitivity scenario results in a 2.9% (£37.4bn), 3.2% (£41.4bn) and 3.7% (£47.5bn) loss to GDP respectively for the three scenarios.

The macroeconomic impact of pandemic influenza: estimates from models of the United Kingdom, France, Belgium and The Netherlands

The 2003 outbreak of severe acute respiratory syndrome (SARS) showed that infectious disease outbreaks can have notable macroeconomic impacts. The current H1N1 and potential H5N1 flu pandemics could have a much greater impact. Using a multi-sector single country computable general equilibrium model of the United Kingdom, France, Belgium and The Netherlands, together with disease scenarios of varying severity, we examine the potential economic cost of a modern pandemic. Policies of school closure, vaccination and antivirals, together with prophylactic absence from work are evaluated and their cost impacts are estimated. Results suggest GDP losses from the disease of approximately 0.5-2% but school closure and prophylactic absenteeism more than triples these effects. Increasing school closures from 4 weeks at the peak to entire pandemic closure almost doubles the economic cost, but antivirals and vaccinations seem worthwhile. Careful planning is therefore important to ensure expensive policies to mitigate the pandemic are effective in minimising illness and deaths.

The possible macroeconomic impact on the UK of an influenza pandemic

Little is known about the possible impact of an influenza pandemic on a nation's economy. We applied the UK macroeconomic model 'COMPACT' to epidemiological data on previous UK influenza pandemics, and extrapolated a sensitivity analysis to cover more extreme disease scenarios. Analysis suggests that the economic impact of a repeat of the 1957 or 1968 pandemics, allowing for school closures, would be short-lived, constituting a loss of 3.35 and 0.58% of GDP in the first pandemic quarter and year, respectively. A more severe scenario (with more than 1% of the population dying) could yield impacts of 21 and 4.5%, respectively. The economic shockwave would be gravest when absenteeism (through school closures) increases beyond a few weeks, creating policy repercussions for influenza pandemic planning as the most severe economic impact is due to policies to contain the pandemic rather than the pandemic itself.Accounting for changes in consumption patterns made in an attempt to avoid infection worsens the potential impact. Our mild disease scenario then shows first quarter/first year reductions in GDP of 9.5/2.5%, compared with our severe scenario reductions of 29.5/6%. These results clearly indicate the significance of behavioural change over disease parameters.

Public health evaluation in the twenty-first century: time to see the wood as well as the trees

This paper argues that concepts, methodologies and practices within public health need further development if they are to be sufficient to allow us to develop, undertake and evaluate interventions in the twenty-first century. The public health profession, and the disciplines that contribute to it, maintains the historical focus upon detailed micro analysis (individual and health sector) and not broader macro analysis (societal and system). This brief paper suggests why this is and outlines three challenges it poses: specifying and evaluating outcomes; specifying and understanding complex causal pathways in social interventions and the development of multisector evaluation, to meet information demands from multiple stakeholders. While there is general agreement that public health evaluation needs development, this paper argues that the focus needs to be more upon a broader evaluative space than is currently practiced. There is a need to move beyond primary and secondary health-related effects upon individuals, and focus more on evaluation of the wider range and distribution of direct and indirect effects upon individuals, communities and populations. That is, those involved in public health evaluation need to step back and first consider the wood before focusing in on specific trees.