Systematic review of economic evaluations of preparedness strategies and interventions against influenza pandemics

A systematic literature review of economic evaluation studies of interventions impacting antimicrobial resistance

BACKGROUND

Antimicrobial resistance (AMR) is accelerated by widespread and inappropriate use of antimicrobials. Many countries, including those in low- and middle- income contexts, have started implementing interventions to tackle AMR. However, for many interventions there is little or no economic evidence with respect to their cost-effectiveness. To help better understand the scale of this evidence gap, we conducted a systematic literature review to provide a comprehensive summary on the value for money of different interventions affecting AMR.

METHODS

A systematic literature review was conducted of economic evaluations on interventions addressing AMR. a narrative synthesis of findings was produced. Systematic searches for relevant studies were performed across relevant databases and grey literature sources such as unpublished studies, reports, and other relevant documents. All identified economic evaluation studies were included provided that they reported an economic outcome and stated that the analysed intervention aimed to affect AMR or antimicrobial use in the abstract. Studies that reported clinical endpoints alone were excluded. Selection for final inclusion and data extraction was performed by two independent reviewers. A quality assessment of the evidence used in the included studies was also conducted.

RESULTS

28,597 articles were screened and 35 articles were identified that satisfied the inclusion criteria. The review attempted to answer the following questions: (1) What interventions to address AMR have been the subject of an economic evaluation? (2) In what types of setting (e.g. high-income, low-income, regions etc.) have these economic evaluations been focused? (3) Which interventions have been estimated to be cost-effective, and has this result been replicated in other settings/contexts? (4) What economic evaluation methods or techniques have been used to evaluate these interventions? (5) What kind and quality of data has been used in conducting economic evaluations for these interventions?

DISCUSSION

The review is one of the first of its kind, and the most recent, to systematically review the literature on the cost-effectiveness of AMR interventions. This review addresses an important evidence gap in the economics of AMR and can assist AMR researchers' understanding of the state of the economic evaluation literature, and therefore inform future research. Systematic review registration PROSPERO (CRD42020190310).

The FLURESP European commission project: cost-effectiveness assessment of ten public health measures against influenza in Italy: is there an interest in COVID-19 pandemic?

BACKGROUND

The FLURESP project is a public health research funded by the European Commission, with the objective to design a methodological framework to assess the cost-effectiveness of existing public health measures against human influenza pandemics. A dataset has been specifically collected in the frame of the Italian health system. As most of interventions against human influenza are relavant against other respiratory diseases pandemics, potential interests in COVID-19 are discussed.

METHODS

Ten public health measures against human influenza pandemics pandemic were selected to be also relevant to other respiratory virus pandemics such as COVID 19: individual (hand washing, using masks), border control (quarantine, fever screening, border closure), community infection (school closure, class dismissal, social distancing, limitation of public transport), reduction of secondary infections (implementation of antibiotic therapy guidelines), pneumococcal vaccination for at-risk people, development of Intensive Care Unit (ICU) capacity, implementation of life support equipments in ICU, screening interventions, vaccination programs targeting health professional and targeting general population.

RESULTS

Using mortality reduction as effectiveness criteria, the most cost-effective strategies are "reduction of secondary infections" and "implementation of life support equipment in ICU". The least cost-effective option whatever the level of pandemic events are screening interventions and mass vaccination.

CONCLUSIONS

A number of intervention strategies against human influenza pandemics appears relevant against every respiratory virus, including the COVID-19 event. Measures against pandemics should be considered according to their expected effectiveness but also their costs for the society because they impose substantial burden to the population, confirming the interest of considering cost-effectiveness of public health measures to enlighten decision making.

Patient flow time data of COVID-19 vaccination clinics in 23 sites, United States, April and May 2021

INTRODUCTION

Public health department (PHD) led COVID-19 vaccination clinics can be a critical component of pandemic response as they facilitate high volume of vaccination. However, few patient-time analyses examining patient throughput at mass vaccination clinics with unique COVID-19 vaccination challenges have been published.

METHODS

During April and May of 2021, 521 patients in 23 COVID-19 vaccination sites counties of 6 states were followed to measure the time spent from entry to vaccination. The total time was summarized and tabulated by clinic characteristics. A multivariate linear regression analysis was conducted to evaluate the association between vaccination clinic settings and patient waiting times in the clinic.

RESULTS

The average time a patient spent in the clinic from entry to vaccination was 9 min 5 s (range: 02:00-23:39). Longer patient flow times were observed in clinics with higher numbers of doses administered, 6 or fewer vaccinators, walk-in patients accepted, dedicated services for people with disabilities, and drive-through clinics. The multivariate linear regression showed that longer patient waiting times were significantly associated with the number of vaccine doses administered, dedicated services for people with disabilities, the availability of more than one brand of vaccine, and rurality.

CONCLUSIONS

Given the standardized procedures outlined by immunization guidelines, reducing the wait time is critical in lowering the patient flow time by relieving the bottleneck effect in the clinic. Our study suggests enhancing the efficiency of PHD-led vaccination clinics by preparing vaccinators to provide vaccines with proper and timely support such as training or delivering necessary supplies and paperwork to the vaccinators. In addition, patient wait time can be spent answering questions about vaccination or reviewing educational materials on other public health services.

Lessons from past pandemics: a systematic review of evidence-based, cost-effective interventions to suppress COVID-19

BACKGROUND

In an unparalleled global response, during the COVID-19 pandemic, 90 countries asked 3.9 billion people to stay home. Yet other countries avoided lockdowns and focused on other strategies, like contact tracing. How effective and cost-effective are these strategies? We aimed to provide a comprehensive summary of the evidence on past pandemic controls, with a focus on cost-effectiveness.

METHODS

Following PRISMA guidelines, MEDLINE (1946 to April week 2, 2020) and EMBASE (1974 to April 17, 2020) were searched using a range of terms related to pandemic control. Articles reporting on the effectiveness or cost-effectiveness of at least one intervention were included.

RESULTS

We found 1653 papers; 62 were included. The effectiveness of hand-washing and face masks was supported by randomized trials. These measures were highly cost-effective. For other interventions, only observational and modelling studies were found. They suggested that (1) the most cost-effective interventions are swift contact tracing and case isolation, surveillance networks, protective equipment for healthcare workers, and early vaccination (when available); (2) home quarantines and stockpiling antivirals are less cost-effective; (3) social distancing measures like workplace and school closures are effective but costly, making them the least cost-effective options; (4) combinations are more cost-effective than single interventions; and (5) interventions are more cost-effective when adopted early. For 2009 H1N1 influenza, contact tracing was estimated to be 4363 times more cost-effective than school closure ($2260 vs. $9,860,000 per death prevented).

CONCLUSIONS AND CONTRIBUTIONS

For COVID-19, a cautious interpretation suggests that (1) workplace and school closures are effective but costly, especially when adopted late, and (2) scaling up as early as possible a combination of interventions that includes hand-washing, face masks, ample protective equipment for healthcare workers, and swift contact tracing and case isolation is likely to be the most cost-effective strategy.

Interventions on Socioeconomic and Racial Inequities in Respiratory Pandemics: a Rapid Systematic Review

Purpose of Review

Racial and socioeconomic inequities in respiratory pandemics have been consistently documented, but little official guidance exists on effective action to prevent these. We systematically reviewed quantitative evaluations of (real or simulated) interventions targeting racial and socioeconomic inequities in respiratory pandemic outcomes.

Recent Findings

Our systematic search returned 10,208 records, of which 5 met inclusion criteria, including observational (n = 1), randomized trial (n = 1), and simulation (n = 3) studies. Interventions studied included vaccination parity, antiviral distribution, school closure, disinfection, personal protective equipment, and paid sick leave, with a focus on Black (n = 3) and/or Latinx (n = 4) or low-SES (n = 2) communities. Results are suggestive that these interventions might be effective at reducing racial and/or SES disparities in pandemics.

Summary

There is a dearth of research on strategies to reduce pandemic disparities. We provide theory-driven, concrete suggestions for incorporating equity into intervention research for pandemic preparedness, including a focus on social and economic policies.

Economic evaluations of interventions against influenza at workplaces: systematic review

BACKGROUND

The burden of influenza is mostly felt by employees and employers because of increased absenteeism rates, loss of productivity and associated direct costs. Even though interventions against influenza among working adults are effective, patronage and compliance to these measures especially vaccination are low compared to other risk groups.

AIMS

This study was aimed to assess evidence of economic evaluations of interventions against influenza virus infection among workers or in the workplace setting.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guideline for systematic reviews was followed. Three databases, PubMed, Web of Science and EconLit, were searched using keywords to identify relevant articles from inception till 25 October 2020. Original peer-reviewed papers that conducted economic evaluations of influenza interventions using cost-benefit, cost-effectiveness or cost-utility analysis methods focused on working-age adults or work settings were eligible for inclusion. Two independent teams of co-authors extracted and synthesized data from identified studies.

RESULTS

Twenty-four articles were included: 21 were cost-benefit analyses and 3 examined cost-effectiveness analyses. Two papers also presented additional cost-utility analysis. Most of the studies were pharmaceutical interventions (n = 23) primarily focused on vaccination programs while one study was a non-pharmaceutical intervention examining the benefit of paid sick leave. All but two studies reported that interventions against influenza virus infection at the workplace were cost-saving and cost-effective regardless of the analytic approach.

CONCLUSIONS

Further cost-effectiveness research in non-pharmaceutical interventions against influenza in workplace settings is warranted. There is a need to develop standardized methods for reporting economic evaluation methods to ensure comparability and applicability of future research findings.

Economic Aspects of Delivering Primary Care Services: An Evidence Synthesis to Inform Policy and Research Priorities

Policy Points The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. While there is a large amount of literature on the economic aspects of delivering primary care services, there is a need for more comprehensive overviews of this evidence. In this article, we offer such an overview. Evidence suggests that there are several strategies involving coverage, financing, service delivery, and governance arrangements which can, if implemented, have positive economic impacts on the delivery of primary care services. These include arrangements such as worker task-shifting and telemedicine. The implementation of any such arrangements, based on positive economic evidence, should carefully account for potential impacts on overall health care access and quality. There are many opportunities for further research, with notable gaps in evidence on the impacts of increasing primary care funding or the overall supply of primary care services.

CONTEXT

The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. To strengthen primary health care, policymakers need guidance on how to allocate resources in a manner that maximizes its economic benefits.

METHODS

We collated and synthesized published systematic reviews of evidence on the economic aspects of different models of delivering primary care services. Building on previous efforts, we adapted existing taxonomies of primary care components to classify our results according to four categories: coverage, financing, service delivery, and governance.

FINDINGS

We identified and classified 109 reviews that met our inclusion criteria according to our taxonomy of primary care components: coverage, financing, service delivery, and governance arrangements. A significant body of evidence suggests that several specific primary care arrangements, such as health workers' task shifting and telemedicine, can have positive economic impacts (such as lower overall health care costs). Notably absent were reviews on the impact of increasing primary care funding or the overall supply of primary care services.

CONCLUSIONS

There is a great opportunity for further research to systematically examine the broader economic impacts of investing in primary care services. Despite progress over the last decade, significant evidence gaps on the economic implications of different models of primary care services remain, which could help inform the basis of future research efforts.

Social Factors Associated With Adherence to Preventive Behaviors Related to COVID-19 Among Rural and Semi-urban Communities in Western Maharashtra, India

Background: To control the transmission of the coronavirus disease 2019 (COVID-19) infection, the Government of India (GoI) had taken stringent precautionary measures during the lockdown period. This study aimed to explore determinants affecting adherence to protective measures against COVID-19 infection among rural and semi-urban settings of Maharashtra, India.

Methods: A cross-sectional telephonic survey among 1,016 adults from randomly selected households was conducted between June 5 and July 16, 2020. The data were explored for knowledge, awareness, practices related to protective measures, and self-risk perception. Socio-demographic and attitudinal correlates of failure to use protective measures against COVID-19 were measured.

Results: In the survey, 72% of the participants were men. The mean age was 46 years (SD: 13.8). The main source of information was television (91%); however, information from healthcare providers (65%) and mass media announcements (49%) was trustworthy. Washing hands immediately with soap after returning from outdoors was reported by 95% of the respondents, always using a mask while outdoors by 94%, never attended social gatherings by 91%, always using hand sanitizer while outside by 77%, and 68% of the respondents followed all protective measures. The knowledge score [mean score 20.3 (SD: 2.4) out of 24] was independently associated with the risk of not using protective measures, with each unit increase in knowledge score, the risk of not using protective measures reduced by 16%. No source of income was independently associated with not using protective measures [AOR 1.5 95% CI (1.01–2.3)].

Conclusions: The COVID-19 public health interventions and behavior change communication strategies should be specifically directed towards the low socio-economic populations through trusted sources. The association between knowledge and practices demonstrates the importance of accurate public health communication to optimally follow preventive measures, such as structural interventions to address poverty and employment policies to address the unemployment crisis are required. Surveillance activity is needed to understand the actual behavior change among the population.

Cost-effectiveness of public health interventions against human influenza pandemics in France: a methodological contribution from the FLURESP European Commission project

BACKGROUND

The FLURESP project is a public health project funded by the European Commission with the objective to design a methodological approach in order to compare the cost-effectiveness of existing public health measures against human influenza pandemics in four target countries: France, Italy, Poland and Romania. This article presents the results relevant to the French health system using a data set specifically collected for this purpose.

METHODS

Eighteen public health interventions against human influenza pandemics were selected. Additionally, two public-health criteria were considered: 'achieving mortality reduction ≥40%' and 'achieving morbidity reduction ≥30%'. Costs and effectiveness data sources include existing reports, publications and expert opinions. Cost distributions were taken into account using a uniform distribution, according to the French health system.

RESULTS

Using reduction of mortality as an effectiveness criterion, the most cost-effective options was 'implementation of new equipment of Extracorporeal membrane oxygenation (ECMO) equipment'. Targeting vaccination to health professionals appeared more cost-effective than vaccination programs targeting at risk populations. Concerning antiviral distribution programs, curative programs appeared more cost-effective than preventive programs. Using reduction of morbidity as effectiveness criterion, the most cost-effective option was 'implementation of new equipment ECMO'. Vaccination programs targeting the general population appeared more cost-effective than both vaccination programs of health professionals or at-risk populations. Curative antiviral programs appeared more cost-effective than preventive distribution programs, whatever the pandemic scenario.

CONCLUSION

Intervention strategies against human influenza pandemics impose a substantial economic burden, suggesting a need to develop public-health cost-effectiveness assessments across countries.

Cost-effectiveness of emergency preparedness measures in response to infectious respiratory disease outbreaks: a systematic review and econometric analysis

OBJECTIVES

Respiratory infectious disease outbreaks pose a threat for loss of life, economic instability and social disruption. We conducted a systematic review of published econometric analyses to assess the direct and indirect costs of infectious respiratory disease outbreaks that occurred between 2003 and 2019.

SETTING

Respiratory infectious disease outbreaks or public health preparedness measures or interventions responding to respiratory outbreaks in OECD countries (excluding South Korea and Japan) so as to assess studies relevant to the European context. The cost-effectiveness of interventions was assessed through a dominance ranking matrix approach. All cost data were adjusted to the 2017 Euro, with interventions compared with the null. We included data from 17 econometric studies.

PRIMARY AND SECONDARY OUTCOME MEASURES

Direct and indirect costs for disease and preparedness and/or response or cost-benefit and cost-utility were measured.

RESULTS

Overall, the economic burden of infectious respiratory disease outbreaks was found to be significant to healthcare systems and society. Indirect costs were greater than direct costs mainly due to losses of productivity. With regard to non-pharmaceutical strategies, prehospitalisation screening and the use of protective masks were identified as both an effective strategy and cost-saving. Community contact reduction was effective but had ambiguous results for cost saving. School closure was an effective measure, but not cost-saving in the long term. Targeted antiviral prophylaxis was the most cost-saving and effective pharmaceutical intervention.

CONCLUSIONS

Our cost analysis results provide evidence to policymakers on the cost-effectiveness of pharmaceutical and non-pharmaceutical intervention strategies which may be applied to mitigate or respond to infectious respiratory disease outbreaks.

Travel-related control measures to contain the COVID-19 pandemic: an evidence map

OBJECTIVES

To comprehensively map the existing evidence assessing the impact of travel-related control measures for containment of the SARS-CoV-2/COVID-19 pandemic.

DESIGN

Rapid evidence map.

DATA SOURCES

MEDLINE, Embase and Web of Science, and COVID-19 specific databases offered by the US Centers for Disease Control and Prevention and the WHO.

ELIGIBILITY CRITERIA

We included studies in human populations susceptible to SARS-CoV-2/COVID-19, SARS-CoV-1/severe acute respiratory syndrome, Middle East respiratory syndrome coronavirus/Middle East respiratory syndrome or influenza. Interventions of interest were travel-related control measures affecting travel across national or subnational borders. Outcomes of interest included infectious disease, screening, other health, economic and social outcomes. We considered all empirical studies that quantitatively evaluate impact available in Armenian, English, French, German, Italian and Russian based on the team's language capacities.

DATA EXTRACTION AND SYNTHESIS

We extracted data from included studies in a standardised manner and mapped them to a priori and (one) post hoc defined categories.

RESULTS

We included 122 studies assessing travel-related control measures. These studies were undertaken across the globe, most in the Western Pacific region (n=71). A large proportion of studies focused on COVID-19 (n=59), but a number of studies also examined SARS, MERS and influenza. We identified studies on border closures (n=3), entry/exit screening (n=31), travel-related quarantine (n=6), travel bans (n=8) and travel restrictions (n=25). Many addressed a bundle of travel-related control measures (n=49). Most studies assessed infectious disease (n=98) and/or screening-related (n=25) outcomes; we found only limited evidence on economic and social outcomes. Studies applied numerous methods, both inferential and descriptive in nature, ranging from simple observational methods to complex modelling techniques.

CONCLUSIONS

We identified a heterogeneous and complex evidence base on travel-related control measures. While this map is not sufficient to assess the effectiveness of different measures, it outlines aspects regarding interventions and outcomes, as well as study methodology and reporting that could inform future research and evidence synthesis.

Costs and benefits of interventions aimed at major infectious disease threats: lessons from the literature

Pandemics and major outbreaks have the potential to cause large health losses and major economic costs. To prioritize between preventive and responsive interventions, it is important to understand the costs and health losses interventions may prevent. We review the literature, investigating the type of studies performed, the costs and benefits included, and the methods employed against perceived major outbreak threats. We searched PubMed and SCOPUS for studies concerning the outbreaks of SARS in 2003, H5N1 in 2003, H1N1 in 2009, Cholera in Haiti in 2010, MERS-CoV in 2013, H7N9 in 2013, and Ebola in West-Africa in 2014. We screened titles and abstracts of papers, and subsequently examined remaining full-text papers. Data were extracted according to a pre-constructed protocol. We included 34 studies of which the majority evaluated interventions related to the H1N1 outbreak in a high-income setting. Most interventions concerned pharmaceuticals. Included costs and benefits, as well as the methods applied, varied substantially between studies. Most studies used a short time horizon and did not include future costs and benefits. We found substantial variation in the included elements and methods used. Policymakers need to be aware of this and the bias toward high-income countries and pharmaceutical interventions, which hampers generalizability. More standardization of included elements, methodology, and reporting would improve economic evaluations and their usefulness for policy.

Cost-Effectiveness of Antiviral Treatments for Pandemics and Outbreaks of Respiratory Illnesses, Including COVID-19: A Systematic Review of Published Economic Evaluations

OBJECTIVE

To review published economic evaluations of antiviral treatment for pandemics and outbreaks of respiratory illnesses.

METHODS

We conducted a systematic review to identify economic evaluations of antiviral treatment for pandemics and outbreaks of respiratory illnesses, including coronavirus disease 2019 (COVID-19). We searched Medline (EBSCOhost), EMBASE (Ovid), EconLit (Ovid), National Health Service Economic Evaluation Database (Ovid), and Health Technology Assessment (Ovid). The search was last rerun on July 5, 2020. Citation tracking and reference checking were used. Only full economic evaluations published as peer-reviewed articles in the last 10 years were included. Studies were quality assessed using the National Institute for Health and Care Excellence economic evaluation checklist.

RESULTS

Overall, 782 records were identified, of which 14 studies met the inclusion criteria. The studies were mostly conducted in high-income countries. All were model-based. Seven (50%) were cost-utility analyses, 4 (28.6%) were cost-effectiveness analyses, 2 (14.3%) were cost-consequences analyses, and 1 (7.1%) was a cost-benefit analysis. Strategies including antiviral treatment were found to be either cost-saving or cost-effective, at the study-specific willingness-to-pay thresholds. Empirical treatment was more cost-effective than test-guided treatment for young adults but less so for older adults.

CONCLUSIONS

Antiviral treatment for managing pandemics and outbreaks of respiratory illnesses that have very high case fatality rate, similar to COVID-19 pandemic, are likely to be cost-effective either as a standalone intervention or part of a multifaceted strategy. Investing in the development of such curative treatments and promptly evaluating their cost-effectiveness, relative to other strategies in use at the time of their introduction should be the focus going forward to inform resource allocation decisions particularly in low- and middle-income countries.

A Country Pandemic Risk Exposure Measurement Model

Purpose

The purpose of this study is to develop a Pandemic Risk Exposure Measurement (PREM) model to determine the factors that affect a country’s prospective vulnerability to a pandemic risk exposure also considering the current COVID-19 pandemic.

Methods

To develop the model, drew up an inventory of possible factor variables that might expose a country’s vulnerability to a pandemic such as COVID-19. This model was based on the analysis of existing literature and consultations with some experts and associations. To support the inventory of selected possible factor variables, we have conducted a survey with participants sampled from people working in a risk management environment carrying out a risk management function. The data were subjected to statistical analysis, specifically exploratory factor analysis and Cronbach Alpha to determine and group these factor variables and determine their reliability, respectively. This enabled the development of the PREM model. To eliminate possible bias, hierarchical regression analysis was carried out to examine the effect of the “Level of Experienced Hazard of the Participant (LEH)” considering also the “Level of Expertise and Knowledge about Risk and Risk Management (LEK)”.

Results

Exploratory factor analysis loaded best on four factors from 19 variables: Demographic Features, Country’s Activity Features, Economic Exposure and Societal Vulnerability (i.e. the PREM Model). This model explains 65.5% of the variance in the level of experienced hazard (LEH). Additionally, we determined that LEK explains only about 2% of the variance in LEH.

Conclusion

The developed PREM model shows that monitoring of Demographic Features, Country’s Activity Features, Economic Exposure and Societal Vulnerability can help a country to identify the possible impact of pandemic risk exposure and develop policies, strategies, regulations, etc., to help a country strengthen its capacity to meet the economic, social and in turn healthcare demands due to pandemic hazards such as COVID-19.

Systematic review of economic evaluation studies on preconception care interventions

Implementation of preconception care interventions have been encouraged for improving maternal and child health outcomes; therefore, evidence on their cost-effectiveness is needed. We conducted the systematic review to examine the efficiency of those interventions by collecting evidence from published economic evaluation studies. Out of 14 included studies, almost all (12/14) were in high-income countries. All studies were not cost-utility analysis with genetic disease screening and diabetes management were the common interventions for evaluating their efficiency during preconception period. Preconception care interventions are likely to be cost-effective, especially in low-income countries which incremental benefits had a greater return than developed nations.

Economic and health impacts of infectious diseases in China: A protocol for systematic review and meta analysis

BACKGROUND

A worldwide concern has been raised that novel infectious diseases may outbreak rapidly with a limited response time due to globalization. Severe Acute Respiratory Syndrome, influenza A, Avian Influenza Virus, and Corona Virus Disease 2019 are acute respiratory diseases that have been affected by the movements of people, and globalization accelerates these movements. These infectious diseases not only have an overwhelming health impact but also impact the worldwide economy.

METHODS

We will conduct a systematic review and meta-analysis in Chinese National Knowledge Infrastructure, WANFANG Database, and the VIP Database for Chinese Technical Periodicals, Web of Science, PubMed, EMBASE, the Cochrane Library, EBSCO host, ProQuest, ProQuest Dissertations & Theses A&I, SAGE Journals, ScienceDirect, JSTOR, and Scopus. We will evaluate the risk of bias of included RCTs according to the criteria and technique proposed in the Cochrane Handbook V.5.1.0 and use ROBINS-I to assess risk of bias in nonrandomized studies. We will use GRADE to evaluate the quality of evidence.

RESULTS

Results of this review will be submitted to a peer-reviewed journal.

CONCLUSION

To the best of our knowledge, this study will firstly evaluate both health and economic impact of infectious diseases in china and may provide strategy development ideas for future resistance.

Investing in antibiotics to alleviate future catastrophic outcomes: What is the value of having an effective antibiotic to mitigate pandemic influenza?

Over 95% of post-mortem samples from the 1918 pandemic, which caused 50 to 100 million deaths, showed bacterial infection complications. The introduction of antibiotics in the 1940s has since reduced the risk of bacterial infections, but growing resistance to antibiotics could increase the toll from future influenza pandemics if secondary bacterial infections are as serious as in 1918, or even if they are less severe. We develop a valuation model of the option to withhold wide use of an antibiotic until significant outbreaks such as pandemic influenza or foodborne diseases are identified. Using real options theory, we derive conditions under which withholding wide use is beneficial, and calculate the option value for influenza pandemic scenarios that lead to secondary infections with a resistant Staphylococcus aureus strain. We find that the value of withholding an effective novel oral antibiotic can be positive and significant unless the pandemic is mild and causes few secondary infections with the resistant strain or if most patients can be treated intravenously. Although the option value is sensitive to parameter uncertainty, our results suggest that further analysis on a case-by-case basis could guide investment in novel agents as well as strategies on how to use them.

People's perception and cost-effectiveness of home confinement during an influenza pandemic: evidence from the French case

In France, home confinement is not a common preventive measure against an influenza pandemic, although it is used around the world. Based on a stated method approach, we analyze the attitude that the French would adopt if this measure were put in place. Next, we propose a cost-benefit analysis to discuss the cost-effectiveness of this measure. We find that over three-quarters of respondents report complying with home confinement. Their choice depends on their individual characteristics, the interaction they may have with an infected person and home confinement conditions, but not their experience with preventive measures. We find that behaviors such as sensitivity to certainty, selfishness and altruism emerge. As far as cost-effectiveness is concerned, our study shows that home confinement is a prevention path that should not be neglected and should even be prescribed.

Model Comparisons of the Effectiveness and Cost-Effectiveness of Vaccination: A Systematic Review of the Literature

OBJECTIVES

To describe all published articles that have conducted comparisons of model-based effectiveness and cost-effectiveness results in the field of vaccination. Specific objectives were to 1) describe the methodologies used and 2) identify the strengths and limitations of the studies.

METHODS

We systematically searched MEDLINE and Embase databases for studies that compared predictions of effectiveness and cost-effectiveness of vaccination of two or more mathematical models. We categorized studies into two groups on the basis of their data source for comparison (previously published results or new simulation results) and performed a qualitative synthesis of study conclusions.

RESULTS

We identified 115 eligible articles (only 5% generated new simulations from the reviewed models) examining the effectiveness and cost-effectiveness of vaccination against 14 pathogens (69% of studies examined human papillomavirus, influenza, and/or pneumococcal vaccines). The goal of most of studies was to summarize evidence for vaccination policy decisions, and cost-effectiveness was the most frequent outcome examined. Only 33%, 25%, and 3% of studies followed a systematic approach to identify eligible studies, assessed the quality of studies, and performed a quantitative synthesis of results, respectively. A greater proportion of model comparisons using published studies followed a systematic approach to identify eligible studies and to assess their quality, whereas more studies using new simulations performed quantitative synthesis of results and identified drivers of model conclusions. Most comparative modeling studies concluded that vaccination was cost-effective.

CONCLUSIONS

Given the variability in methods used to conduct/report comparative modeling studies, guidelines are required to enhance their quality and transparency and to provide better tools for decision making.

Economic evaluation of outpatient parenteral antimicrobial therapy: a systematic review

INTRODUCTION

Outpatient parenteral antimicrobial therapy (OPAT) consists of providing antimicrobial therapy by parenteral infusion without hospitalization. A systematic review was performed to compare OPAT and hospitalization as health care modalities from an economic perspective. Areas covered: We identified 1455 articles using 13 electronic databases and manual searches. Two independent reviewers identified 35 studies conducted between 1978 and 2016. We observed high heterogeneity in the following: countries, infection site, OPAT strategies and outcomes analyzed. Of these, 88% had a retrospective observational design and one was a randomized trial. With respect to economic analyses, 71% of the studies considered the cost-consequences, 11% cost minimization, 6% cost-benefit, 6% cost-utility analyses and 6% cost effectiveness. Considering all 35 studies, the general OPAT cost saving was 57.19% (from -13.03% to 95.47%). Taking into consideration only high-quality studies (6 comparative studies), the cost saving declined by 16.54% (from -13.03% to 46.86%). Expert commentary: Although most studies demonstrate that OPAT is cost-effective, the magnitude of this effect is compromised by poor methodological quality and heterogeneity. Economic assessments of the issue are needed using more rigorous methodologies that include a broad range of perspectives to identify the real magnitude of economic savings in different settings and OPAT modalities.

Value for Money in H1N1 Influenza: A Systematic Review of the Cost-Effectiveness of Pandemic Interventions

BACKGROUND

The 2009 A/H1N1 influenza pandemic generated additional data and triggered new studies that opened debate over the optimal strategy for handling a pandemic. The lessons-learned documents from the World Health Organization show the need for a cost estimation of the pandemic response during the risk-assessment phase. Several years after the crisis, what conclusions can we draw from this field of research?

OBJECTIVE

The main objective of this article was to provide an analysis of the studies that present cost-effectiveness or cost-benefit analyses for A/H1N1 pandemic interventions since 2009 and to identify which measures seem most cost-effective.

METHODS

We reviewed 18 academic articles that provide cost-effectiveness or cost-benefit analyses for A/H1N1 pandemic interventions since 2009. Our review converts the studies' results into a cost-utility measure (cost per disability-adjusted life-year or quality-adjusted life-year) and presents the contexts of severity and fatality.

RESULTS

The existing studies suggest that hospital quarantine, vaccination, and usage of the antiviral stockpile are highly cost-effective, even for mild pandemics. However, school closures, antiviral treatments, and social distancing may not qualify as efficient measures, for a virus like 2009's H1N1 and a willingness-to-pay threshold of $45,000 per disability-adjusted life-year. Such interventions may become cost-effective for severe crises.

CONCLUSIONS

This study helps to shed light on the cost-utility of various interventions, and may support decision making, among other criteria, for future pandemics. Nonetheless, one should consider these results carefully, considering these may not apply to a specific crisis or country, and a dedicated cost-effectiveness assessment should be conducted at the time.

Global economic evaluations of rotavirus vaccines: A systematic review

INTRODUCTION

World Health Organization (WHO) recommends Rotavirus vaccines to prevent and control rotavirus infections. Economic evaluations (EE) have been considered to support decision making of national policy. Summarizing global experience of the economic value of rotavirus vaccines is crucial in order to encourage global WHO recommendations for vaccine uptake. Therefore, a systematic review of economic evaluations of rotavirus vaccine was conducted.

METHODS

We searched Medline, Embase, NHS EED, EconLit, CEA Registry, SciELO, LILACS, CABI-Global Health Database, Popline, World Bank - e-Library, and WHOLIS. Full economic evaluations studies, published from inception to November 2015, evaluating Rotavirus vaccines preventing Rotavirus infections were included. The methods, assumptions, results and conclusions of the included studies were extracted and appraised using WHO guide for standardization of EE of immunization programs.

RESULTS

104 relevant studies were included. The majority of studies were conducted in high-income countries. Cost-utility analysis was mostly reported in many studies using incremental cost-effectiveness ratio per DALY averted or QALY gained. Incremental cost per QALY gained was used in many studies from high-income countries. Mass routine vaccination against rotavirus provided the ICERs ranging from cost-saving to highly cost-effective in comparison to no vaccination among low-income countries. Among middle-income countries, vaccination offered the ICERs ranging from cost-saving to cost-effective. Due to low- or no subsidized price of rotavirus vaccines from external funders, being not cost-effective was reported in some high-income settings.

CONCLUSION

Mass vaccination against rotavirus was generally found to be cost-effective, particularly in low- and middle-income settings according to the external subsidization of vaccine price. On the other hand, it may not be a cost-effective intervention at market price in some high-income settings. This systematic review provides supporting information to health policy-makers and health professionals when considering rotavirus vaccination as a national program.

Effectiveness of personal protective measures in reducing pandemic influenza transmission: A systematic review and meta-analysis

The goal of this review was to examine the effectiveness of personal protective measures in preventing pandemic influenza transmission in human populations. We collected primary studies from Medline, Embase, PubMed, Cochrane Library, CINAHL and grey literature. Where appropriate, random effects meta-analyses were conducted using inverse variance statistical calculations. Meta-analyses suggest that regular hand hygiene provided a significant protective effect (OR=0.62; 95% CI 0.52-0.73; I²=0%), and facemask use provided a non-significant protective effect (OR=0.53; 95% CI 0.16-1.71; I²=48%) against 2009 pandemic influenza infection. These interventions may therefore be effective at limiting transmission during future pandemics. PROSPERO Registration: 42016039896.

Assessing the State of Knowledge Regarding the Effectiveness of Interventions to Contain Pandemic Influenza Transmission: A Systematic Review and Narrative Synthesis

BACKGROUND

Influenza pandemics occur when a novel influenza strain, to which humans are immunologically naïve, emerges to cause infection and illness on a global scale. Differences in the viral properties of pandemic strains, relative to seasonal ones, can alter the effectiveness of interventions typically implemented to control seasonal influenza burden. As a result, annual control activities may not be sufficient to contain an influenza pandemic.

PURPOSE

This study seeks to inform pandemic policy and planning initiatives by reviewing the effectiveness of previous interventions to reduce pandemic influenza transmission and infection. Results will inform the planning and design of more focused in-depth systematic reviews for specific types of interventions, thus providing the most comprehensive and current understanding of the potential for alternative interventions to mitigate the burden of pandemic influenza.

METHODS

A systematic review and narrative synthesis of existing systematic reviews and meta-analyses examining intervention effectiveness in containing pandemic influenza transmission was conducted using information collected from five databases (PubMed, Medline, Cochrane, Embase, and Cinahl/EBSCO). Two independent reviewers conducted study screening and quality assessment, extracting data related to intervention impact and effectiveness.

RESULTS AND DISCUSSION

Most included reviews were of moderate to high quality. Although the degree of statistical heterogeneity precluded meta-analysis, the present systematic review examines the wide variety of interventions that can impact influenza transmission in different ways. While it appears that pandemic influenza vaccination provides significant protection against infection, there was insufficient evidence to conclude that antiviral prophylaxis, seasonal influenza cross-protection, or a range of non-pharmaceutical strategies would provide appreciable protection when implemented in isolation. It is likely that an optimal intervention strategy will employ a combination of interventions in a layered approach, though more research is needed to substantiate this proposition.

TRIAL REGISTRATION

PROSPERO 42016039803.

The validity of clinical practice guidelines for empirical use of oseltamivir for influenza in Thai children

BACKGROUND

Clinical practice guidelines for influenza have been implemented to maximise the appropriate use of empirical oseltamivir; however, good predictive values are required.

METHODS

Between October 2011 and September 2013, children aged < 15 years who presented at the Bamrasnaradura Infectious Diseases Institute with an influenza-like illness plus either (i) pneumonia or (ii) being in a higher risk group for influenza complications were prospectively enrolled. Respiratory specimens were taken for real-time polymerase chain reaction testing (RT-PCR). Clinical characteristics, laboratory data and oseltamivir therapy were recorded.

RESULTS

85 cases were enrolled. Of these, the proportions of those with pneumonia, who were aged < 2 years and who had underlying diseases were 74.1%, 56.5% and 38.8%, respectively. RT-PCR detected respiratory syncytial virusamong (35.3%), influenza (22.3by%), adenovirus (14.1%), human metapneumovirus (5.9%), para-influenza (3.5%) and no viruses (25.9 %). Pneumonia (OR 0.16, 95% CI 0.05-0.50) and having two clinical criteria (OR 0.24, 95% CI 0.08-0.76) were significantly negative predictors of influenza. Having cluster transmissions (OR 5.18, 95% CI 1.38-19.37) and a monocyte proportion >7% (OR 3.58, 95% CI 1.15-11.17) were significantly positive predictors of influenza. The mean (SD) percentage of influenza-like illness during the study period was 7.04 (2.02).

CONCLUSIONS

Clinical criteria guidelines yielded a low predictive value (22.3%) for influenza in children. Seasonality, cluster transmission, white blood cell and differential counts may be helpful in diagnosing influenza. Nonetheless, empirical oseltamivir should not be delayed for those in need.

Dynamic Transmission Economic Evaluation of Infectious Disease Interventions in Low- and Middle-Income Countries: A Systematic Literature Review

Economic evaluation using dynamic transmission models is important for capturing the indirect effects of infectious disease interventions. We examine the use of these methods in low- and middle-income countries, where infectious diseases constitute a major burden. This review is comprised of two parts: (1) a summary of dynamic transmission economic evaluations across all disease areas published between 2011 and mid-2014 and (2) an in-depth review of mosquito-borne disease studies focusing on health economic methods and reporting. Studies were identified through a systematic search of the MEDLINE database and supplemented by reference list screening. Fifty-seven studies were eligible for inclusion in the all-disease review. The most common subject disease was HIV/AIDS, followed by malaria. A diverse range of modelling methods, outcome metrics and sensitivity analyses were used, indicating little standardisation. Seventeen studies were included in the mosquito-borne disease review. With notable exceptions, most studies did not employ economic evaluation methods beyond calculating a cost-effectiveness ratio or net benefit. Many did not adhere to health care economic evaluations reporting guidelines, particularly with respect to full model reporting and uncertainty analysis. We present a summary of the state-of-the-art and offer recommendations for improved implementation and reporting of health economic methods in this crossover discipline.

Economic Evaluation in Global Perspective: A Bibliometric Analysis of the Recent Literature

We present a bibliometric analysis of recently published full economic evaluations of health interventions and reflect critically on the implications of our findings for this growing field. We created a database drawing on 14 health, economic, and/or general literature databases for articles published between 1 January 2012 and 3 May 2014 and identified 2844 economic evaluations meeting our criteria. We present findings regarding the sensitivity, specificity, and added value of searches in the different databases. We examine the distribution of publications between countries, regions, and health areas studied and compare the relative volume of research with disease burden. We analyse authors' country and institutional affiliations, journals and journal type, language, and type of economic evaluation conducted. More than 1200 economic evaluations were published annually, of which 4% addressed low-income countries, 4% lower-middle-income countries, 14% upper-middle-income countries, and 83% high-income countries. Across country income levels, 53, 54, 86, and 100% of articles, respectively, included an author based in a country within the income level studied. Biomedical journals published 74% of economic evaluations. The volume of research across health areas correlates more closely with disease burden in high-income than in low-income and middle-income countries. Our findings provide an empirical basis for further study on methods, research prioritization, and capacity development in health economic evaluation.

Climate influences on the cost-effectiveness of vector-based interventions against malaria in elimination scenarios

Despite the dependence of mosquito population dynamics on environmental conditions, the associated impact of climate and climate change on present and future malaria remains an area of ongoing debate and uncertainty. Here, we develop a novel integration of mosquito, transmission and economic modelling to assess whether the cost-effectiveness of indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) against Plasmodium falciparum transmission by Anopheles gambiae s.s. mosquitoes depends on climatic conditions in low endemicity scenarios. We find that although temperature and rainfall affect the cost-effectiveness of IRS and/or LLIN scale-up, whether this is sufficient to influence policy depends on local endemicity, existing interventions, host immune response to infection and the emergence rate of insecticide resistance. For the scenarios considered, IRS is found to be more cost-effective than LLINs for the same level of scale-up, and both are more cost-effective at lower mean precipitation and higher variability in precipitation and temperature. We also find that the dependence of peak transmission on mean temperature translates into optimal temperatures for vector-based intervention cost-effectiveness. Further cost-effectiveness analysis that accounts for country-specific epidemiological and environmental heterogeneities is required to assess optimal intervention scale-up for elimination and better understand future transmission trends under climate change.

Review of economic evaluations of mask and respirator use for protection against respiratory infection transmission

BACKGROUND

There has been increasing debate surrounding mask and respirator interventions to control respiratory infection transmission in both healthcare and community settings. As decision makers are considering the recommendations they should evaluate how to provide the most efficient protection strategies with minimum costs. The aim of this review is to identify and evaluate the existing economic evaluation literature in this area and to offer advice on how future evaluations on this topic should be conducted.

METHODS

We searched the Scopus database for all literature on economic evaluation of mask or respirator use to control respiratory infection transmission. Reference lists from the identified studies were also manually searched. Seven studies met our inclusion criteria from the initial 806 studies identified by the search strategy and our manual search.

RESULTS

Five studies considered interventions for seasonal and/or pandemic influenza, with one also considering SARS (Severe Acute Respiratory Syndrome). The other two studies focussed on tuberculosis transmission control interventions. The settings and methodologies of the studies varied greatly. No low-middle income settings were identified. Only one of the reviewed studies cited clinical evidence to inform their mask/respirator intervention effectiveness parameters. Mask and respirator interventions were generally reported by the study authors to be cost saving or cost-effective when compared to no intervention or other control measures, however the evaluations had important limitations.

CONCLUSIONS

Given the large cost differential between masks and respirators, there is a need for more comprehensive economic evaluations to compare the relative costs and benefits of these interventions in situations and settings where alternative options are potentially applicable. There are at present insufficient well conducted cost-effectiveness studies to inform decision-makers on the value for money of alternative mask/respirator options.

Effectiveness of travel restrictions in the rapid containment of human influenza: a systematic review

OBJECTIVE

To assess the effectiveness of internal and international travel restrictions in the rapid containment of influenza.

METHODS

We conducted a systematic review according to the requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Health-care databases and grey literature were searched and screened for records published before May 2014. Data extraction and assessments of risk of bias were undertaken by two researchers independently. Results were synthesized in a narrative form.

FINDINGS

The overall risk of bias in the 23 included studies was low to moderate. Internal travel restrictions and international border restrictions delayed the spread of influenza epidemics by one week and two months, respectively. International travel restrictions delayed the spread and peak of epidemics by periods varying between a few days and four months. Travel restrictions reduced the incidence of new cases by less than 3%. Impact was reduced when restrictions were implemented more than six weeks after the notification of epidemics or when the level of transmissibility was high. Travel restrictions would have minimal impact in urban centres with dense populations and travel networks. We found no evidence that travel restrictions would contain influenza within a defined geographical area.

CONCLUSION

Extensive travel restrictions may delay the dissemination of influenza but cannot prevent it. The evidence does not support travel restrictions as an isolated intervention for the rapid containment of influenza. Travel restrictions would make an extremely limited contribution to any policy for rapid containment of influenza at source during the first emergence of a pandemic virus.

Glycan receptor specificity as a useful tool for characterization and surveillance of influenza A virus

Influenza A viruses are rapidly evolving pathogens with the potential for novel strains to emerge and result in pandemic outbreaks in humans. Some avian-adapted subtypes have acquired the ability to bind to human glycan receptors and cause severe infections in humans but have yet to adapt to and transmit between humans. The emergence of new avian strains and their ability to infect humans has confounded their distinction from circulating human virus strains through linking receptor specificity to human adaptation. Herein we review the various structural and biochemical analyses of influenza hemagglutinin-glycan receptor interactions. We provide our perspectives on how receptor specificity can be used to monitor evolution of the virus to adapt to human hosts so as to facilitate improved surveillance and pandemic preparedness.

Insights into the human glycan receptor conformation of 1918 pandemic hemagglutinin-glycan complexes derived from nuclear magnetic resonance and molecular dynamics studies

The glycan receptor binding and specificity of influenza A viral hemagglutinin (HA) are critical for virus infection and transmission in humans. However, ambiguities in the interpretation of the receptor binding specificity of hemagglutinin from human- and avian-adapted viruses have prevented an understanding of its relationship with aerosol transmissibility, an exclusive property of human-adapted viruses. A previous conformational study, which we performed, indicated that human and avian receptors sample distinct conformations in solution. On the basis of detailed nuclear magnetic resonance (NMR) studies provided herein, we offer evidence of the distinct structural constraints imposed by hemagglutinin receptor binding sites on the glycan conformational space upon binding. The hemagglutinin from the SC18 virus, which has efficient aerosol transmissibility in humans (human-adapted), imposed the most stringent constraints on the conformational space of the human glycan receptor (LSTc), compared to single (NY18) or double (AV18) amino acid HA mutants, a property correlating to the ligand–HA binding strength. This relationship was also observed for the avian-adapted HA, where the high affinity binding partner, AV18, imposed the most stringent conformational constraints on the avian receptor, compared to those imposed by NY18. In particular, it is interesting to observe how different HAs when binding to human or avian glycosidic receptors impose significantly different conformational states, in terms of the states sampled by the glycosidic backbone and/or the entire molecule shape (linear or bent), when compared to the corresponding unbound glycans. Significantly, we delineate a “characteristic NMR signature” for the human adapted hemagglutinin (SC18) binding to human glycan receptors. Therefore, the conformational space constraints imposed by the hemagglutinin receptor binding site provide a characteristic signature that could be a useful tool for the surveillance of human adaptation of other (such as H7N9 and H5N1) deadly influenza viruses.

Detection of the influenza A(H1N1)pdm09 virus carrying the K-15E, P83S and Q293H mutations in patients who have undergone bone marrow transplant

The 2009 pandemic influenza A(H1N1)pdm09 virus emerged and caused considerable morbidity and mortality in the third world, especially in Brazil. Although circulating strains of A(H1N1)pdm09 are A/California/04/2009-like (CA-04-like) viruses, various studies have suggested that some mutations in the viral hemagglutinin (HA) may be associated with enhanced severity and fatality. This phenomenon is particularly challenging for immunocompromised individuals, such as those who have undergone bone marrow transplant (BMT), because they are more likely to display worse clinical outcomes to influenza infection than non-immunocompromised individuals. We studied the clinical and viral aspects of post-BMT patients with confirmed A(H1N1)pdm09 diagnosis in the largest cancer hospital in Brazil. We found a viral strain with K-15E, P83S and Q293H polymorphisms in the HA, which is presumably more virulent, in these individuals. Despite that, these patients showed only mild symptoms of infection. Our findings complement the discovery of mild cases of infection with the A(H1N1)pdm09 virus with the K-15E, P83S and Q293H mutations in Brazil and oppose other studies that have linked these changes with increased disease severity. These results could be important for a better comprehension of the impact of the pandemic influenza in the context of BMT.

Assessing key model parameters for economic evaluation of pandemic influenza interventions: the data source matters

BACKGROUND

In our previous systematic review of economic evaluations of pandemic influenza interventions, five model parameters, namely probability of pandemic, duration of pandemic, severity, attack rate, and intervention efficacy, were not only consistently used in all studies but also considered important by authors.

OBJECTIVES

Because these parameters originated from sources of varying quality ranging from experimental studies to expert opinion, this study aims to analyze the variation in values used according to sources of information across studies.

METHODS

An analysis of estimated values of key parameters for economic modeling was performed against their different data sources, following the standard hierarchy of evidence.

RESULTS

A lack of good-quality evidence to estimate pandemic duration, pandemic probability, and mortality reduction from antiviral treatment results in a large variation of values used in economic evaluations. Although there are variations in quality of evidence used for attack rate, basic reproduction number, and reduction in hospitalizations from antiviral treatment, the estimated values do not vary significantly. The use of higher-quality evidence results in better precision of estimated values compared to lower-quality sources.

CONCLUSION

Hierarchies of evidence are a necessary tool to identify appropriate model parameters to populate economic evaluations and should be included in methodological guidelines. Knowledge gaps in some key parameters should be addressed, because if good-quality evidence is available, future economic evaluations will be more reliable. Some gaps may not be fulfilled by research but consensus among experts to ensure consistency in the use of these assumptions.

Communicating risk and promoting disease mitigation measures in epidemics and emerging disease settings

OBJECTIVE

This review aims to identify and assess evidence on interventions to communicate risk and promote disease mitigation measures in epidemics and emerging disease outbreak settings. The study focuses on data that are relevant to low and middle-income country (LMIC) settings.

METHODS

We conducted a comprehensive literature search using five major electronic databases (Pubmed Medline, Biomed Central, EMBASE, Science of Citation Index, and Cochrane Library) and other sources to identify relevant studies published from January 2002 to July 2013. The review was guided by the socio-ecological model/perspective of public health and the ideation theory and focused on interventions at the community, healthcare, and multi-sectoral settings, which also reflect key intervention levels of the Ottawa Charter for Health Promotion. Eligible quantitative studies were selected according to specific study criteria and assessed using the Critical Appraisal Skills Program (CASP) framework. Conversely, qualitative studies, reviews, case studies, and editorials were not included. Studies were selected by two independent reviewers.

RESULTS

Twenty-nine relevant studies from 16 countries were included. Most studies focused on a single intervention or intervention level, rather than multi-sectoral interventions. The majority of the evidence relates to programs aimed at behavioral and social results (or relevant intermediate steps) within a specific population group. Two studies included implications for improvements in health service delivery, two studies examined the intervention's impact on health systems-related outcomes, and three had also implications for environmental health outcomes. Cost- and health equity-related implications for select evidence were also discussed.

CONCLUSIONS

The paucity of well-designed quantitative evaluations of interventions to communicate health risk and promote disease control measures in LMICs does not allow for any definitive conclusions. Yet, the review identified several promising interventions and areas for future investigation. Among them, community-based and participatory interventions seemed to be central within epidemic and emerging disease settings, particularly in low-resource settings. Yet, evidence on their effectiveness is not conclusive and needs to be explored by future studies. Other promising areas for future investigation include multi-component and multi-sectoral approaches to intervention design. Major research gaps referred to any evaluation of the impact of these kinds of interventions on health policy adoption and/or implementation, and social determinants of health. Research on cost-effectiveness also needs to be strengthened. This review identified several research gaps and questions, and discusses potential future directions for increasing capacity for future and more rigorous assessments.

Buy now, saved later? The critical impact of time-to-pandemic uncertainty on pandemic cost-effectiveness analyses

Background Investment in pandemic preparedness is a long-term gamble, with the return on investment coming at an unknown point in the future. Many countries have chosen to stockpile key resources, and the number of pandemic economic evaluations has risen sharply since 2009. We assess the importance of uncertainty in time-to-pandemic (and associated discounting) in pandemic economic evaluation, a factor frequently neglected in the literature to-date.

Methods We use a probability tree model and Monte Carlo parameter sampling to consider the cost effectiveness of antiviral stockpiling in Cambodia under parameter uncertainty. Mean elasticity and mutual information (MI) are used to assess the importance of time-to-pandemic compared with other parameters. We also consider the sensitivity to choice of sampling distribution used to model time-to-pandemic uncertainty.

Results Time-to-pandemic and discount rate are the primary drivers of sensitivity and uncertainty in pandemic cost effectiveness models. Base case cost effectiveness of antiviral stockpiling ranged between is US$112 and US$3599 per DALY averted using historical pandemic intervals for time-to-pandemic. The mean elasticities for time-to-pandemic and discount rate were greater than all other parameters. Similarly, the MI scores for time to pandemic and discount rate were greater than other parameters. Time-to-pandemic and discount rate were key drivers of uncertainty in cost-effectiveness results regardless of time-to-pandemic sampling distribution choice.

Conclusions Time-to-pandemic assumptions can “substantially” affect cost-effectiveness results and, in our model, is a greater contributor to uncertainty in cost-effectiveness results than any other parameter. We strongly recommend that cost-effectiveness models include probabilistic analysis of time-to-pandemic uncertainty.

Was mandatory quarantine necessary in China for controlling the 2009 H1N1 pandemic?

The Chinese government enforced mandatory quarantine for 60 days (from 10 May to 8 July 2009) as a preventative strategy to control the spread of the 2009 H1N1 pandemic. Such a prevention strategy was stricter than other non-pharmaceutical interventions that were carried out in many other countries. We evaluated the effectiveness of the mandatory quarantine and provide suggestions for interventions against possible future influenza pandemics. We selected one city, Beijing, as the analysis target. We reviewed the epidemiologic dynamics of the 2009 H1N1 pandemic and the implementation of quarantine measures in Beijing. The infectious population was simulated under two scenarios (quarantined and not quarantined) using a deterministic Susceptible-Exposed-Infectious-Recovered (SEIR) model. The basic reproduction number R0 was adjusted to match the epidemic wave in Beijing. We found that mandatory quarantine served to postpone the spread of the 2009 H1N1 pandemic in Beijing by one and a half months. If mandatory quarantine was not enforced in Beijing, the infectious population could have reached 1,553 by 21 October, i.e., 5.6 times higher than the observed number. When the cost of quarantine is taken into account, mandatory quarantine was not an economically effective intervention approach against the 2009 H1N1 pandemic. We suggest adopting mitigation methods for an influenza pandemic with low mortality and morbidity.

Health technology assessments as a mechanism for increased value for money: recommendations to the Global Fund

The Global Fund is experiencing increased pressure to optimize results and improve its impact per dollar spent. It is also in transition from a provider of emergency funding, to a long-term, sustainable financing mechanism. This paper assesses the efficacy of current Global Fund investment and examines how health technology assessments (HTAs) can be used to provide guidance on the relative priority of health interventions currently subsidized by the Global Fund. In addition, this paper identifies areas where the application of HTAs can exert the greatest impact and proposes ways in which this tool could be incorporated, as a routine component, into application, decision, implementation, and monitoring and evaluation processes. Finally, it addresses the challenges facing the Global Fund in realizing the full potential of HTAs.

Trends in parameterization, economics and host behaviour in influenza pandemic modelling: a review and reporting protocol

BACKGROUND

The volume of influenza pandemic modelling studies has increased dramatically in the last decade. Many models incorporate now sophisticated parameterization and validation techniques, economic analyses and the behaviour of individuals.

METHODS

We reviewed trends in these aspects in models for influenza pandemic preparedness that aimed to generate policy insights for epidemic management and were published from 2000 to September 2011, i.e. before and after the 2009 pandemic.

RESULTS

We find that many influenza pandemics models rely on parameters from previous modelling studies, models are rarely validated using observed data and are seldom applied to low-income countries. Mechanisms for international data sharing would be necessary to facilitate a wider adoption of model validation. The variety of modelling decisions makes it difficult to compare and evaluate models systematically.

CONCLUSIONS

We propose a model Characteristics, Construction, Parameterization and Validation aspects protocol (CCPV protocol) to contribute to the systematisation of the reporting of models with an emphasis on the incorporation of economic aspects and host behaviour. Model reporting, as already exists in many other fields of modelling, would increase confidence in model results, and transparency in their assessment and comparison.

Cost-effectiveness of influenza control measures: a dynamic transmission model-based analysis

We investigated the cost-effectiveness of different influenza control strategies in a school setting in Taiwan. A susceptible-exposure-infected-recovery (SEIR) model was used to simulate influenza transmission and we used a basic reproduction number (R 0)-asymptomatic proportion (θ) control scheme to develop a cost-effectiveness model. Based on our dynamic transmission model and economic evaluation, this study indicated that the optimal cost-effective strategy for all modelling scenarios was a combination of natural ventilation and respiratory masking. The estimated costs were US$10/year per person in winter for one kindergarten student. The cost for hand washing was estimated to be US$32/year per person, which was much lower than that of isolation (US$55/year per person) and vaccination (US$86/year per person) in containing seasonal influenza. Transmission model-based, cost-effectiveness analysis can be a useful tool for providing insight into the impacts of economic factors and health benefits on certain strategies for controlling seasonal influenza.

Virulence attenuation during an influenza A/H5N1 pandemic

More than 15 years after the first human cases of influenza A/H5N1 in Hong Kong, the world remains at risk for an H5N1 pandemic. Preparedness activities have focused on antiviral stockpiling and distribution, development of a human H5N1 vaccine, operationalizing screening and social distancing policies, and other non-pharmaceutical interventions. The planning of these interventions has been done in an attempt to lessen the cumulative mortality resulting from a hypothetical H5N1 pandemic. In this theoretical study, we consider the natural limitations on an H5N1 pandemic's mortality imposed by the virus' epidemiological–evolutionary constraints. Evolutionary theory dictates that pathogens should evolve to be relatively benign, depending on the magnitude of the correlation between a pathogen's virulence and its transmissibility. Because the case fatality of H5N1 infections in humans is currently 60 per cent, it is doubtful that the current viruses are close to their evolutionary optimum for transmission among humans. To describe the dynamics of virulence evolution during an H5N1 pandemic, we build a mathematical model based on the patterns of clinical progression in past H5N1 cases. Using both a deterministic model and a stochastic individual-based simulation, we describe (i) the drivers of evolutionary dynamics during an H5N1 pandemic, (ii) the range of case fatalities for which H5N1 viruses can successfully cause outbreaks in humans, and (iii) the effects of different kinds of social distancing on virulence evolution. We discuss two main epidemiological–evolutionary features of this system (i) the delaying or slowing of an epidemic which results in a majority of hosts experiencing an attenuated virulence phenotype and (ii) the strong evolutionary pressure for lower virulence experienced by the virus during a period of intense social distancing.

Advances and future challenges in recombinant adenoviral vectored H5N1 influenza vaccines

The emergence of a highly pathogenic avian influenza virus H5N1 has increased the potential for a new pandemic to occur. This event highlights the necessity for developing a new generation of influenza vaccines to counteract influenza disease. These vaccines must be manufactured for mass immunization of humans in a timely manner. Poultry should be included in this policy, since persistent infected flocks are the major source of avian influenza for human infections. Recombinant adenoviral vectored H5N1 vaccines are an attractive alternative to the currently licensed influenza vaccines. This class of vaccines induces a broadly protective immunity against antigenically distinct H5N1, can be manufactured rapidly, and may allow mass immunization of human and poultry. Recombinant adenoviral vectors derived from both human and non-human adenoviruses are currently being investigated and appear promising both in nonclinical and clinical studies. This review will highlight the current status of various adenoviral vectored H5N1 vaccines and will outline novel approaches for the future.