Increased risk of rhinovirus infection in children during the coronavirus disease-19 pandemic

Background

Coronavirus disease (COVID‐19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), was first detected in Japan in January 2020 and has spread throughout the country. Previous studies have reported that viral interference among influenza virus, rhinovirus, and other respiratory viruses can affect viral infections at the host and population level.

Methods

To investigate the impact of COVID‐19 on influenza and other respiratory virus infections, we analyzed clinical specimens collected from 2244 patients in Japan with respiratory diseases between January 2018 and September 2020.

Results

The frequency of influenza and other respiratory viruses (coxsackievirus A and B; echovirus; enterovirus; human coronavirus 229E, HKU1, NL63, and OC43; human metapneumovirus; human parainfluenza virus 1, 2, 3, and 4; human parechovirus; human respiratory syncytial virus; human adenovirus; human bocavirus; human parvovirus B19; herpes simplex virus type 1; and varicella‐zoster virus) was appreciably reduced among all patients during the COVID‐19 pandemic except for that of rhinovirus in children younger than 10 years, which was appreciably increased. COVID‐19 has not spread among this age group, suggesting an increased risk of rhinovirus infection in children.

Conclusions

Rhinovirus infections should be continuously monitored to understand their increased risk during the COVID‐19 pandemic and viral interference with SARS‐CoV‐2.

Cost-effectiveness analysis of influenza vaccination during pregnancy in Japan

BACKGROUND

Pregnant women and infants are known as high risk groups for influenza. WHO recommend pregnant women be vaccinated with inactivated influenza vaccine. In Japan, some municipalities started to give subsidy to encourage pregnant women to receive a shot on their own accord, which has made the introduction of seasonal antepartum maternal vaccination program (AMVP) into the routine vaccination list a current topic in health policy and has raised the need to evaluate the value for money of such possibility.

METHODS

We conducted a cost-effectiveness analysis to evaluate the efficiency of conducting AMVP in Japan. A decision tree model was adopted taking into consideration the duration of single-year vaccine effectiveness for infants and for mothers. The program targeted pregnant women aged 20-49 years old at or over 12 weeks gestation during October 1 through March 30. Estimated probabilities of treatments received due to influenza for pregnant/postpartum women or their infants varied by calendar time, vaccination status, and/or gestational age. Incremental cost-effectiveness ratio (ICER) compared with current no-AMVP from societal perspective was calculated. Transition probabilities, utility weights to estimate quality-adjusted life year (QALY), and disease treatment costs were either calculated or extracted from literature. Costs per vaccination was assumed at ¥3,529/US$32.1.

RESULTS

AMVP reduces disease treatment costs, while the reduction cannot offset the vaccination cost. Incremental QALYs were at 0.00009, among them 84.2% were from infants. ICER was ¥7,779,356/US$70,721 per QALY gained. One-way sensitivity analyses revealed that vaccine effectiveness for infant and costs per shot were the two main key variables affecting the ICER.

CONCLUSION

We found that vaccinating pregnant women with influenza vaccine to prevent unvaccinated infants and pregnant/postpartum women from influenza-associated disease in Japan can be cost-effective from societal perspective, under the WHO-suggested "cost-effective" criteria (1-3 times of GDP).

Genetic and antigenic characterisation of influenza A(H3N2) viruses isolated in Yokohama during the 2016/17 and 2017/18 influenza seasons

Background: Influenza A(H3N2) virus rapidly evolves to evade human immune responses, resulting in changes in the antigenicity of haemagglutinin (HA). Therefore, continuous genetic and antigenic analyses of A(H3N2) virus are necessary to detect antigenic mutants as quickly as possible.

Aim: We attempted to phylogenetically and antigenically capture the epidemic trend of A(H3N2) virus infection in Yokohama, Japan during the 2016/17 and 2017/18 influenza seasons.

Methods: We determined the HA sequences of A(H3N2) viruses detected in Yokohama, Japan during the 2016/17 and 2017/18 influenza seasons to identify amino acid substitutions and the loss or gain of potential N-glycosylation sites in HA, both of which potentially affect the antigenicity of HA. We also examined the antigenicity of isolates using ferret antisera obtained from experimentally infected ferrets.

Results: Influenza A(H3N2) viruses belonging to six clades (clades 3C.2A1, 3C.2A1a, 3C.2A1b, 3C.2A2, 3C.2A3 and 3C.2A4) were detected during the 2016/17 influenza season, whereas viruses belonging to two clades (clades 3C.2A1b and 3C.2A2) dominated during the 2017/18 influenza season. The isolates in clades 3C.2A1a and 3C.2A3 lost one N-linked glycosylation site in HA relative to other clades. Antigenic analysis revealed antigenic differences among clades, especially clade 3C.2A2 and 3C.2A4 viruses, which showed distinct antigenic differences from each other and from other clades in the antigenic map.

Conclusion: Multiple clades, some of which differed antigenically from others, co-circulated in Yokohama, Japan during the 2016/17 and 2017/18 influenza seasons.

Predominant Detection of the Subgroup A2b Human Metapneumovirus Strain with a 111-Nucleotide Duplication in the G gene in Yokohama City, Japan in 2018

Human metapneumovirus (HMPV) has been a major causative agent of acute respiratory infections in humans. Recently, two types of variant A2b subtype HMPV strains possessing a 111- or 180-nucleotide duplication (nt-dup) in the G gene (HMPV A2b_180nt-dup and HMPV A2b_111nt-dup, respectively) were detected in Japan, Spain, Vietnam, and China. Our surveillance for infectious agents in Yokohama City, Japan revealed that the HMPV A2b_111nt-dup strain became predominant in Yokohama City in 2018. In contrast, no classic HMPV A2b strain was detected after 2017. These data indicate a beneficial role of the 111nt-dup in the G gene for the transmission of HMPV.

Mass Spectrometric Analysis of Synthetic Organic Pigments

Though synthetic organic colorants are used in various applications nowadays, there is the concern that impurities by-produced during the manufacturing and degradation products in some of these colorants are persistent organic pollutants and carcinogens. Thus, it is important to identify the synthetic organic colorants in various products, such as commercial paints, ink, cosmetics, food, textile, and plastics. Dyes, which are soluble in water and other solvents, could be analyzed by chromatographic methods. In contrast, it is difficult to analyze synthetic organic pigments by these methods because of their insolubility. This review is an overview of mass spectrometric analysis of synthetic organic pigments by various ionization methods. We highlight a recent study of textile samples by atmospheric pressure solid analysis probe MS. Furthermore, the mass spectral features of synthetic organic pigments and their separation from other components such as paint media and plasticizers are discussed.

A novel 111-nucleotide duplication in the G gene of human metapneumovirus

In 2017, novel human metapneumovirus (HMPV) A2b subgroup strains with a 111-nucleotide duplication in the G gene was detected by the present team. These strains were related to previously identified HMPV A2b strains with a 180-nucleotide duplication; however, they appeared to be different strains, produced by an independent duplication event. The recent evolution of HMPV suggests that careful monitoring of this virus is required.

Economic evaluation of routine infant rotavirus immunisation program in Japan

Two rotavirus vaccines are currently available in Japan. We estimated the incremental cost-effectiveness ratio (ICER) of routine infant rotavirus immunisation program without defining which vaccine to be evaluated, which reflects the current deliberation at the Health Science Council in charge of Immunisation and Vaccine established by the Ministry of Health, Labor and Welfare of Japan. Three ICERs were estimated, one from payers' perspective and 2 from societal perspective depending on the scenarios to uptake vaccines. The health statuses following the birth cohort were as follows: not infected by rotavirus, asymptomatic infection, outpatients after infection, hospitalised after infection, developing encephalitis/encephalopathy followed by recovery, sequelae, and death. Costs of per course of vaccination was ¥30,000 (US$283; US$1 = ¥106). The model runs for 60 months with one month cycle. From payers' perspective, estimated ICERs were ¥6,877,000 (US$64,877) per QALY. From societal perspective, immunisation program turns out to be cost-saving for 75% simultaneous vaccination scenario, while it is at ¥337,000 (US$3,179) per QALY gained with vaccine alone scenario. The probability of rotavirus immunisation program to be under ¥5,000,000 (US$47,170) per QALY was at 19.8%, 40.7%, and 75.6% when costs per course of vaccination were set at ¥30,000 (US$283), ¥25,000 (US$236), and ¥20,000 (US$189), respectively. Rotavirus immunisation program has a potential to be cost-effective from payers' perspective and even cost-saving from societal perspective in Japan, however, caution should be taken with regard to the interpretation of the results as cost-effectiveness is critically dependent on vaccination costs.

Evaluation of health-related quality of life for hypothesized medical states associated with cervical cancer

BACKGROUND

When evaluating health-economics for cervical cancer prevention policies in Japan, it is important to use Japanese value settings. This study aimed to obtain preference-based measures (preference measures) for hypothesized health states among healthy Japanese women, and to examine differences between the EuroQol-5D (EQ-5D) and standard gamble (SG) instruments.

MATERIALS AND METHODS

The investigation was performed among female students at a nursing university. We used written hypothetical scenarios describing three grades of cervical intraepithelial neoplasia (CIN) and eight stages of cervical cancer, both at diagnosis and after medical intervention. Preference measures were evaluated using both EQ-5D and SG.

RESULTS

We received responses from 136 women. The mean number of respondents per stage was 24.6 (SD: 2.7). At diagnosis, average EQ-5D scores for CIN1, CIN2, CIN3, IA1, IA2, IB1, IB2, IIA, IIB, III, and IV stages were 0.84 (0.14), 0.78 (0.12), 0.73 (0.10), 0.78 (0.12), 0.72 (0.12), 0.63 (0.13), 0.64 (0.12), 0.68 (0.08), 0.62 (0.13), 0.55 (0.21), and 0.18 (0.24), respectively. Using one-way analysis of variance with the Tukey-Kramer method for multiple comparisons (each stage vs. CIN1), we found significant differences for IB1 and more advanced stages (p<0.05). After medical intervention, corresponding EQ-5D scores were 0.84 (0.12), 0.81 (0.12), 0.84 (0.12), 0.80 (0.15), 0.78 (0.11), 0.64 (0.15), 0.63 (0.15), 0.71 (0.15), 0.50 (0.17), 0.52 (0.17), 0.21 (0.28). The multiple comparisons identified significant differences for IB1 and more advanced stages, excepting IIA (p<0.05). SG evaluations were more variable and relatively higher than EQ-5D evaluations.

CONCLUSIONS

We obtained preference measures for three grades of CIN1-3 and eight stages of cervical cancer. In combination with appropriate sensitivity analyses, these preference measures will provide a basis for an economic evaluation of cervical cancer prevention in Japan. We suggest that EQ-5D is appropriate for cost-utility analysis of this topic.

Willingness to pay for public health services in rural Central Java, Indonesia: methodological considerations when using the contingent valuation method

In the health sectors of low- and middle-income countries, contingent valuation method (CVM) studies on willingness to pay (WTP) have been used to gather information on demand variation or financial perspectives alongside price setting, such as the introduction of user fees and valuation of quality improvements. However, WTP found in most CVM studies have only explored the preferences that consumers express through their WTP without exploring whether they are actually able to pay for it. Therefore, this study examines the issues pertaining to WTP estimation for health services using the conventional CVM. We conducted 202 household interviews in 2008, in which we asked respondents about three types of public health services in Indonesia and assessed WTP estimated by the conventional CVM as well as in the scenario of "resorting to debt" to recognize their budget constraints. We find that all the demand curves for both WTP scenarios show gaps. Furthermore, the gap for midwife services is negatively affected by household income and is larger for the poor. These results prove that CVM studies on WTP do not always reveal WTP in the latter scenario. Those findings suggest that WTP elicited by the conventional CVM is different to that from the maximum price that prevents respondents from resorting to debt as their WTP. In order to bridge this gap in the body of knowledge on this topic, studies should improve the scenarios that CVM analyses use to explore WTP. Furthermore, because valuing or pricing health services based on the results of CVM studies on WTP alone can exacerbate the inequity of access to these services, information provided by such studies requires careful interpretation when used for this purpose, especially for the poor and vulnerable sections of society.

[Prognostic prediction of the functional capacity and effectiveness of functional improvement program of the musculoskeletal system among users of preventive care service under long-term care insurance]

OBJECTIVE

The purpose of this study was to examine the effectiveness of the Functional Improvement Program of the Musculoskeletal System among users of Preventive Care Service under Long-Term Care Insurance.

METHODS

A total of 3,073 subjects were analyzed. We used the prediction formula to estimate the predicted value of the Kihon Checklist after one year, and calculated the measured value minus the predicted value. The subjects were divided into two groups according to the measured value minus predicted value tertiles: the lowest and middle tertile (good-to-fair measured value) and the highest tertile (poor measured value). We used a multiple logistic regression model to calculate the odds ratio (OR) and 95% confidence interval (CI) of the good-to-fair measured values of the Kihon Checklist after one year, according to the Functional Improvement Program of the Musculoskeletal System.

RESULTS

In potentially dependent elderly, the multivariate adjusted ORs (95% CI) of the good-to-fair measured values were 2.4 (1.3-4.4) for those who attended the program eight times or more in a month (vs those who attended it three times or less in a month), 1.3 (1.0-1.8) for those who engaged in strength training using machines (vs those who did not train), and 1.4 (1.0-1.9) for those who engaged in endurance training.

CONCLUSIONS

In this study, among potentially dependent elderly, those who attended the program eight times or more in a month and those who engaged in strength training using machines or endurance training showed a significant improvement of their functional capacity.

[Activities in daily life and changes in care level among users of Preventive Care Service under Long-Term Care Insurance]

OBJECTIVES

The aim of this study was to investigate the association between social roles (engaged in working outside or house work) or hobbies and changes in care level among users of Preventive Care Service under Long-Term Care Insurance.

METHODS

A total of 8,734 Preventive Care Service users were analyzed. The assessment was conducted between February 2007 and December 2008. The improvement, maintenance, and aggravation in care level were defined by changes in care level from the beginning to the end. To assess their activities in daily life, the participants were asked, "Which is the major activity in your daily life? Please select one from the following: working outside, house work, hobbies, watching television, others, or none." We used the multiple logistic regression model to calculate the odds ratio (OR) and 95% confidence interval (CI) of the maintenance or improvement in care level according to the category of activity.

RESULTS

As compared with subjects who answered none, the multivariate adjusted ORs (95% CI) of the maintenance or improvement in care level were 2.0 (1.4-2.9) for those who answered working outside, 1.5 (1.2-1.8) for those who answered house work, and 1.5 (1.2-1.9) for those who answered hobbies. However, those who answered watching television or others did not show a significant association with the maintenance or improvement in care level.

CONCLUSIONS

In this study, compared with subjects who answered none, those who answered that they were engaged in working outside, house work, or hobbies were associated with having significantly higher ORs of the maintenance or improvement in care level.

Demand for pneumococcal vaccination under subsidy program for the elderly in Japan

Background

Vaccination programs often organize subsidies and public relations in order to obtain high uptake rates and coverage. However, effects of subsidies and public relations have not been studied well in the literature. In this study, the demand function of pneumococcal vaccination among the elderly in Japan is estimated, incorporating effects of public relations and subsidy.

Methods

Using a data from a questionnaire survey sent to municipalities, the varying and constant elasticity models were applied to estimate the demand function. The response variable is the uptake rate. Explanatory variables are: subsidy supported shot price, operating years of the program, target population size for vaccination, shot location intensity, income and various public relations tools. The best model is selected by c-AIC, and varying and constant price elasticities are calculated from estimation results.

Results

The vaccine uptake rate and the shot price have a negative relation. From the results of varying price elasticity, the demand for vaccination is elastic at municipalities with a shot price higher than 3,708 JPY (35.7 USD). Effects of public relations on the uptake rate are not found.

Conclusions

It can be suggested that municipalities with a shot price higher than 3,708 JPY (35.7 USD) could subsidize more and reduce price to increase the demand for vaccination. Effects of public relations are not confirmed in this study, probably due to measurement errors of variables used for public relations, and studies at micro level exploring individual’s response to public relations would be required.

[Analysis of parent-child sleeping and living habits related to later bedtimes in children]

PURPOSE

To find the relationship between parents' sleeping and living behaviors and their children's sleeping habits, and to investigate factors specifically related to children staying up late in recent Japan.

METHODS

During regular health check-ups of children at three local health centers in the city A, we recruited the parents of one-and-half-year-old and three-year-old children to participate in the Child Sleep Cohort Project (ChiSCoP). Parents of 184 children who consented to participation were mailed three questionnaires by placement method. These are "sleeping diary for 10 days," "sleeping and lifetime rhythm survey," and "emotional behavior assessment scale (CBCL : Child Behavior Checklist 2rd/3rd edition)," of which valid data on 178 children were collected over two years and analyzed.

ANALYSIS

Participants' demographic data, perceived and actual sleeping and living habits, and bedtime patterns were compared among the groups classified by bedtime of children. Bedtimes were classified as early (before 21 : 00), normal (21 : 00 to 21 : 59), and late (after 22 : 00). Using one-way analysis of variance with two (early vs. late) and three bedtime categories, significant differences were found among the three bedtime categories about childcare environmental factors (meal, daytime activity, TV, nap, and bath). So we performed logistic regression analysis with "late bedtime" as the dependent variable and scores of environmental factors (upper or lower than median values) as independent variables in a stepwise manner to eliminate collinear variables and to obtain adjusted odds ratios.

RESULTS

1) Among the 178 children, 96 and 82 were recruited during the physical check-up for one-and-half-year-old and three-years-old, respectively. There were 49, 72, and 57 children in the early, normal, and late bedtime groups, respectively, and no significant difference in attribute factors was found. 2) In children of the early bedtime group, proportions of those with "efforts to establish good life rhythm" (P < 0.0001), "efforts to cultivate sleeping habits" (P < 0.0001), and "keeping a regular bedtime" (P < 0.05) were significantly higher, as well as for children who had more than 105 minutes of "daytime nap" compared to children who had less (P < 0.05). 3) Children's bedtimes were significantly correlated with "mother's wake-up time on weekdays" (r = 0.33) and "mother's bedtime on weekdays" (r = 0.33). Children's wake-up times were also correlated with "mother's wake-up time on weekdays and weekends" (r = 0.49) and "mother's bedtime on weekdays" (r = 0.34), which indicates that children's wake-up times had relationship with mother's sleeping and life habits. 4) Later "wake-up time on weekends" (odds ratio = 4.9) and "regular bedtime hour" (odds ratio = 3.53) were found to be the determinant of late bedtimes of children.

CONCLUSIONS

To encourage earlier bedtimes in children, it is important to take he mother's sleeping and living habits into account and to maintain a regular wake-up and bedtime schedule across weekdays and weekends.

[Generation of appraisal standards for functional measurements in the frail elderly and persons aged 40 and older requiring light assistance in daily living]

OBJECTIVE

The purpose of this study was to generate appraisal standards for functional measures in independent elderly people with physical frailty, "Tokutei", or persons aged 40 and older who require light assistance, "Youshien".

METHODS

A total of 3,852 subjects for whom functional measures were available, including grasp strength, one-leg standing time, timed up & go (TUG) , and 5-m walking time, were analyzed from a database obtained from the Ministry of Health, Labour and Welfare. The upper limit and lower limit of each quintilededuced from the functional measurements were adopted to construct the appraisal standard.

RESULTS

The functional measures were higher in Tokutei than in Youshien. Comparing Tokutei and Yoshien, one or more level difference in the five divided groups was observed for the one-leg standing time. There were differences of three or more levels between Tokutei and Yoshien in the TUG and the 5-m walking time.

CONCLUSION

The present study allowed development of appraisal standards for elderly having physical frailty and for persons aged 40 and older requiring light assistance in daily living.

[Pricing and uptake rate of public funded pneumococcal vaccination for the elderly in Japan]

PURPOSE

The number of municipalities that offer a pneumococcal pneumonia vaccine (PPV) to their aged inhabitants has been increasing. In this study, a complete count survey of the practice of municipality-organized PPV vaccination programs was carried out to explore co-payment/subsidy levels and uptake rates.

METHOD

A questionnaire inquiring into the price charged to the vaccinee, the subsidy provided by the municipality, the size of the target population, and the numbers of individuals vaccinated from 2001 to 2007 was sent to 63 municipal authorities which had organized PPV vaccination programs. Annual changes of co-payment/subsidy and uptake rates are examined with analysis of variance (excluding the year with n < or = 2).

RESULTS

The number of municipalities that provided a subsidy was 1 in 2001, 2 in 2002, 18 in both 2003 and 2004, 24 in 2005, 41 in 2006, and 56 in 2007. Average levels of subsidy were 3233 yen in 2003, 3225 yen in 2004, 3168 yen in 2005, 3158 yen in 2006, and 3351 yen in 2007. Average levels of co-payment are 3899 yen in 2003, 3928 yen in 2004, 3979 yen in 2005, 3891 yen in 2006 and 3672 yen in 2007. No significant differences were found among average levels of subsidy/co-payment between consecutive years (F = 0.195, p = 0.964/F = 0.271, p = 0.949). Average uptake rates by number of years since the beginning of the program (response rate 68.1%, 109/160) were 17.7% for the 1st-year, and 5.4%, 3.7%, 3.4%, 4.6% for the 2nd- to 5th-years, respectively. Statistically significant differences were observed between the 1st- and each of the following years (Dunnett T3, p < 0.001). Average uptake rates in the first year of the program (response rate 80.9%, 51/63) were 32.1% in 2003, 8.5% in 2005, 13.6% in 2006 and 16.5% in 2007. Significant differences were observed between 2003 and 2005 (Tukey's HSD, p = 0.03), and 2003 and 2006 (Tukey's HSD, P = 0.015).

CONCLUSION

Our results revealed levels of co-payment/subsidy and uptake rates of municipality-organized PPV vaccination programs for the first time.

Comparison of public and private care management agencies under public long-term care insurance in Japan: a cross-sectional study

AIM

Long-Term Care Insurance (LTCI), which started in April 2000, allowed private business corporations to provide long-term care services which had been provided by social welfare corporations or public agencies in the previous long-term care scheme. This study compared differences in care management plans for community-dwelling frail elderly people between public care management agencies and private care management agencies.

METHODS

The subjects were 309 community-dwelling frail elderly people living in a suburban city with a population of approximately 55,000 and who had been using community-based long-term care services of the LTCI for 6 months from April 2000. The characteristics of the care management agencies (public/private) were identified using a claims database. After comparing profiles of users and their care mix between those managed by public agencies and by private agencies, the effect of the characteristics of care management agencies on LTCI service use was examined.

RESULTS

Public care management agencies favored younger subjects (P = 0.003), male subjects (P = 0.006) and people with a higher need for care (P = 0.02) than private agencies. The number of service items used was significantly larger in public agencies than in their private counterparts. In multivariate regression analysis, the utilization of community-based long-term care service was significantly greater among beneficiaries managed by private agencies than those managed by public agencies (P = 0.02).

CONCLUSION

Private care management agencies play an important role in promoting the use of care services, but their quality of care plans might be questionable.

Utility weights for allergic rhinitis based on a community survey with a time trade-off technique in Japan

BACKGROUND

Allergic rhinitis is not a fatal disease, but its symptoms deteriorate the quality of life. High morbidity raises a concern about its impact on health care resources. Utility weights, which are required for cost-utility analysis by the level of severity, have not been established to date. This study aims to derive the weights based on a community survey with a time trade-off technique.

METHODS

Self-administered monthly time trade-off questionnaires were administered to representative samples in the community. Four levels of severity were defined by clinical stratification proposed in the "Practical Guideline for the Management of Allergic Rhinitis in Japan".

RESULTS

146 responses (response rate: 51.0%) were collected. Utility weights by the four levels of severity were found to be 0.96, 0.94, 0.89 and 0.83, from mild to severest symptoms, respectively. These values were found to be statistically independent from the respondent's characteristics such as sex, age, existence of current nasal symptoms or history of allergic rhinitis.

CONCLUSIONS

The authors consider that the elicited utility weights are reliable. The results of this study could facilitate economic evaluations regarding allergic rhinitis in various contexts, contributing to better management of the disease.

Does subsidy work? Price elasticity of demand for influenza vaccination among the elderly in Japan

Objectives

Subsidy for influenza vaccination is often provided to the elderly in order to encourage them to receive a flu shot in developed countries. However, its effect on uptake rate, i.e., price elasticity of demand, has not been well studied.

Methods

Japan's decentralised vaccination programme allows observation of various pairs in price and uptake rate of flu shots among the elderly by the municipality from 2001/2002 to 2004/2005 season. We combine our sample survey data (n = 281), which monitor price, subsidy and uptake rate, with published data on local characteristics in order to estimate price elasticity of demand with panel model.

Results

We find price elasticity of demand for influenza vaccine: nearly zero in nationwide, nearly zero in urban area, and −1.07 in rural area.

Conclusions

The results question the rationale for subsidy, especially in urban area. There are cases where maintaining or increasing the level of subsidy is not an efficient allocation of finite health care resources. When organising a vaccination programme, health manager should be careful about the balance between subsidy and other efforts in order to encourage the elderly to receive shots with price elasticity in mind.

[Study on pricing and uptake rate of influenza vaccination for the elderly in Japan with a simple random sampling method]

PURPOSE

In 2001, Japan launched a nationwide subsidy program for influenza immunization of the elderly, whose implementation was devolved to municipalities. Rapid appraisal of the financial impact and utilisation are helpful for evaluating public programs. The government appraised uptake rate with a resource-consuming complete survey. In the present study, the authors carried out a simple and easy sample survey, with a simple random sampling method, to estimate averages of co-payment, subsidy, and total price for one vaccination. The utility of a simple random sampling method for a nationwide survey is also discussed.

METHOD

A total of 300 individuals were randomly selected from about 22 million senior citizens in the 2001/2 season. A questionnaire is sent to their municipal authorities, inquiring about the price of vaccination, the target population size, and the numbers of vaccinated seniors from 2001/2 to 2004/5. Annual changes and the differences between urban and rural areas were examined with analysis of variance and regression analysis.

RESULTS

The response rate is 94.0%. Nationwide average prices of vaccination in terms of co-payment, subsidy, and total price changes from 2001/2 to 2004/5 were as follows: the co-payments were yen 1134, yen 1136, yen 1139, yen 1129 and yen 1148; the subsidies were yen 2972, yen 2955, yen 2966, yen 2954 and yen 2941; and the total prices are yen 4194, yen 4169, yen 4178, yen 4156 and yen 4142. No statistically significant differences were found in the annual rates. Vaccine uptake rates from 2001/2 to 2003/4 were 29.9%, 37.8%, 46.1%, 49.6%, showing a statistically significant increase.

CONCLUSION

These are the first estimates of price and uptake rates of influenza vaccination for the elderly in Japan by a sample survey method. The results demonstrate that the co-payment, subsidies, and the total price have not changed significantly since the program started, but that uptake has improved. The results also suggest that simple random sampling methods are useful for rapid appraisal of the nationwide trends with public programs devolved to municipalities.

Cost–effectiveness analysis of influenza vaccination for people aged 65 and over in Japan

In 2001, Japan launched a national influenza immunisation program for the elderly which provides a subsidy. In order to evaluate the efficiency of the strategy taken in this current program which provides 71% subsidy for all and explore alternative strategies, authors carried out a cost-effectiveness analysis. Authors compared strategies with different levels of subsidy and the use of risk-base targeting by constructing a decision tree model based on the literature. Incremental cost-effectiveness ratios of alternative strategies were estimated deterministically and probabilistically from societal perspective. Probabilistically estimated mean incremental cost-effectiveness ratio of current strategy is US$ 15,535 per YOLS, which can be concluded that current program is cost-effective. Authors also conclude that switching from current strategy to strategy which provides 100% subsidy for all, or strategy which provides 100% subsidy for high-risk elderlies only, can be cost-effective as well.

[Research on choices of people with mild symptoms of common cold between consulting physicians and taking OTC (over-the-counter) medicine using a hypothetical question method]

PURPOSE

This study was aimed at predicting the demand for medical services of people with mild symptoms of common cold. Three alternatives to cope with this condition were presented in questionnaires, which were: consulting physicians, taking OTC (over-the-counter) medicine, and doing nothing. Our prediction of employees' choices with these alternatives will contribute to cost-containment policies of health insurers.

METHOD

We mailed questionnaires to 12,000 selected randomly employees, insured by "A" health insurance company. The questionnaires were designed a hypothetical question method, utilizing several criteria, including number of OTC medicines on hand, and socioeconomic status. A multinomial probit model was used for our estimation and analysis, with alternatives set as dependent variables.

RESULTS

There were 3139 respondents, and the response rate was 26.2%. Gender, age, number of family members, and income level did not have any significant effect on the choice of any of the three alternaives. On the other hand, having a family doctor and a number of OTC medicines on hand had significant consequences. In males with a family doctor and without OTC medicine, the probabilities of choose to consult with a physicians, take on OTC medication, or doing nothing, were predicted to be 0.46, 0.32, and 0.22, respectively. People with three or more kinds of OTC medicine are more likely to choose OTC medication than physicians.

CONCLUSION

The study suggests that more kinds of OTC medicine on hand of for individual with mild symptoms of common cold, the leaves the demand for medical services. To reduce medical expenses through consulting medical services, it might be effective for health insurers to provide insured employees with incentives to keep more OTC medicines on hand.

Prediction of smallpox outbreak and evaluation of control-measure policy in Japan, using a mathematical model

Since the September 1 terrorist attacks and moreover, since the anthrax exposure events in 2001 in the United States, bioterrorism attacks seem to be a real threat. Of course, the public health authorities in Japan have started to prepare control measures for such events. We report here our attempts, using a mathematical model, to estimate outbreak size and to examine the most effective measures; comparing ring vaccination (contact tracing, isolation, and vaccination among contacts) and mass vaccination of the susceptible population in the area. The basic framework of the mathematical model follows a model used in previous research. The initial susceptible population is assumed to be 30 million persons. Concerning the important parameters, such as the number of initial-exposure cases, R₀ (infectious power, or natural history) and, the starting day of intervention after the initial exposure, we checked the robustness of our conclusions by sensitivity analysis. We found that mass vaccination is preferable to ring vaccination when the values for the initial-exposure cases and R₀ are high and when the start of intervention by public health authorities is delayed. In the base-case situation, the mass vaccination strategy needs almost 30 million vaccine doses. On the other hand, though ring vaccination needs fewer doses, it needs fewer than 50 000 doses in the worst-case scenario, that with larger first exposure, higher R₀, or later start of public health authority intervention. This mathematical model can measure the prevalence of an infectious disease and can evaluate control measures for it before an outbreak. Especially, it is useful for the planning of the outbreaks of emerging diseases such as severe acute respiratory syndrome (SARS) or for bioterrorism attacks involving such diseases as smallpox. In further research, we will have to take into account the population people vaccinated of for smallpox, who account for about 70% of the total population in Japan.

Cost-effectiveness of letrozole versus tamoxifen as first-line hormonal therapy in treating postmenopausal women with advanced breast cancer in Japan

The objective of this study is to evaluate the cost-effectiveness of letrozole compared with tamoxifen as first-line therapy in post-menopausal women with advanced breast cancer in Japan. A Markov analytical model was developed to estimate life-year (LY) expectancies, using key transition probabilities obtained from the results of a multinational phase III trial, a literature review and a Japanese medical expert panel. Direct medical costs were estimated, from the payer's perspective, using the expected resource utilization provided by the expert panel, the medical fee table and drug tariff under the national health insurance system. The expected overall life-years (LYs) obtained were 3.68 years for letrozole arm and 3.09 years for tamoxifen arm, showing incremental LYs of 0.59 years in patients receiving letrozole. The total expected costs were 3,644,588 yen (33,133 US dollars) for letrozole arm and 3,322,111 yen (30,201 US dollars) for tamoxifen arm, resulting in a mean incremental cost-effectiveness ratio (ICER) of 546,571 yen (4,969 US dollars) per life-year gained, while the 5 th percentile of ICER showed letrozole dominating tamoxifen and the 95th percentile was 2,310,593 yen (21,005 US dollars). The results suggest that letrozole is a clinically beneficial and cost-effective treatment option when compared with tamoxifen in first-line therapy for advanced breast cancer in Japan.

[Transition of branched-chain amino acids and tyrosine ratio (BTR) in the blood of acute hepatitis patients]

The molar ratio of branched-chain amino acids to tyrosine (BTR) correlates well with the Fischer ratio, and can be measured in a short period of time. It is regarded as the method of analysis that will eventually replace the Fischer ratio. But clinical significance of BTR in terms of acute liver disorders has not been examined thoroughly as of yet. In this study, we measured BTR of 34 patients with acute hepatitis, and examined the transition of the acute period of acute hepatitis and its recovery process. Thirty-four patients diagnosed with acute viral hepatitis became subjects of examination (16 patients of A type, 15 patients of B type, 1 patient of C type, 2 patients of non-A, non-B, non-C type). Out of the 34 patients, 11 were in serious stages (HPT under 40%), including 3 in fulminant condition. By using preserved serum obtained during the acute period (within 1 week of the highest transaminase value), recovery period (within 4 weeks), and treatment period (3 months and later), measurements were conducted with Diacolor:BTR (enzymatic analysis, ONO Pharmaceutical Co., Ltd.), and the results were compared with those of 50 healthy subjects (25 men, 25 women). BTR correlated well with the Fischer ratio for chronic hepatic patients, and with albumin (Alb), PT, and ICGR15 as well, proving that it is useful as an indicator of hepatic reserve ability. But BTR has not been thoroughly examined as it relates to acute liver disorders. In this study, BTR fell in the acute period, correlating with the serious period, proving that it is a useful indicator. For acute liver damage, BTR supports conventional indicators (Alb, Ch-E, HGF, etc.) for assessing serious damage. Also, it has been suggested that measuring the passage of BTR could be the indicator of true recovery, including amino acid metabolism for liver disorders.

[Proper use of laboratory tests from a perspective of health insurance administration]

The national medical expenditure increases at a rate of 1 trillion yen a year, and the expenditure for 1992 is estimated to be about 23 trillion yen. One of the most important jobs of the Health Insurance Administration is to control the medical expenditure. Every time the medical fee is amended, laboratory tests are always the target of the cost containment. In the past, the biochemical tests have been separated into the cost for performance of test, and the cost for assessment of the results, the cost of tests for specific diseases has been comprised, or fixed, and the fee of EKG, EEG, Echo etc after the first has been forced to be reduced. These are all administrative policies, but ultimately, they must be selected properly by the physician who requests these tests. In the future, a system should be established which enables the physician to efficiently (cost-efficiently) select the most appropriate test. For this purpose, undergraduates and post-graduates should learn the concepts of clinical epidemiology and clinical economics. These academic disciplines should be incorporated to increase the value of the treatment. Furthermore, the physician should be given economical incentive of proper use of medical resources.

Cost-effectiveness analysis of mass screening for breast cancer in Japan

The official Japanese recommendation for breast cancer screening is physical examination by a physician, in contrast to US recommendations of mammography. In this analysis of breast cancer screening, the authors used Japanese data in a cost-effectiveness model to compare the following five strategies: (1) no screening (N); (2) physical examination alone (PE); (3) mammography (MG); (4) PE followed by MG if PE findings were abnormal (PE----MG); and (5) PE combined with MG for all screened women (PE + MG). None of these programs would save medical expenditures. The total discounted net costs per patient (in US dollars) were as follows: N, +54; PE, +412; MG, +517; PE----MG, +340; and PE + MG, +731. The number of years of life saved per cohort of 100,000 asymptomatic Japanese women would range from 708 (PE----MG) to 3724 (PG + MG). The additional cost of each strategy (compared with N) per additional year of life would be +49,700 for PE, +40,400 for PE----MG, +14,300 for MG, and +18,000 for PE + MG. The least costly screening option (PE----MG) does not have the lowest cost per additional year of life saved (MG does). MG would be preferable to the current Japanese recommendation of PE alone.

[Amygdaloid kindling in weanling rat and rekindling upon maturization]

To understand the epileptic phenomenon in the immature brain and to investigate whether or not the epileptogenesis acquired in young age is retained after maturation, we carried out the amygdaloid kindling preparation (AM-K) on rat. Ten 3-week-old Wistar rats (3-week-old group) and ten 10-week-old rats (10-week-old group) were stimulated every 2 hours during 09:00-17:00, from five days after operation (Experiment 1). Nine kindled weanling rats (K-group) and ten weanling rats with no stimulation only electrodes implantation (non-K-group) were rekindled upon maturization (Experiment II). Stages of AM-K were classified according to the criteria of Racine. The results obtained were as follows: 1) The 3-week-old group needed significantly fewer stimulations and a shorter AD-durations during early stages (C0-2) of amygdaloid kindling, in comparison with the 10-week-old group. However, there was no significant difference between the two groups as to stimulations and AD-duration during later stages (C3-4) of the kindling. 2) The K-group were rekindled significantly fewer stimulations and a shorter AD-durations than non-K group during early stages. On the other hand, there was not significant difference between the two groups as to stimulation and AD-duration during later stages of the kindling. From the results, the following conclusions were made; The seizure susceptibility of weanling rat's limbic system is high and the epileptogenesis in the limbic system can be maintained even up to adulthood.