Cost-effectiveness analysis of quadrivalent influenza vaccination in at-risk adults and the elderly: an updated analysis in the U.K

OBJECTIVE

To update an earlier evaluation estimating the cost-effectiveness of quadrivalent influenza vaccination (QIV) compared with trivalent influenza vaccination (TIV) in the adult population currently recommended for influenza vaccination in the UK (all people aged ≥65 years and people aged 18-64 years with clinical risk conditions).

METHODS

This analysis takes into account updated vaccine prices, reference costs, influenza strain circulation, and burden of illness data. A lifetime, multi-cohort, static Markov model was constructed with seven age groups. The model was run in 1-year cycles for a lifetime, i.e., until the youngest patients at entry reached the age of 100 years. The base-case analysis was from the perspective of the UK National Health Service, with a secondary analysis from the societal perspective. Costs and benefits were discounted at 3.5%. Herd effects were not included. Inputs were derived from systematic reviews, peer-reviewed articles, and government publications and databases. One-way and probabilistic sensitivity analyses were performed.

RESULTS

In the base-case, QIV would be expected to avoid 1,413,392 influenza cases, 41,780 hospitalizations, and 19,906 deaths over the lifetime horizon, compared with TIV. The estimated incremental cost-effectiveness ratio (ICER) was £14,645 per quality-adjusted life-year (QALY) gained. From the societal perspective, the estimated ICER was £13,497/QALY. A strategy of vaccinating only people aged ≥65 years had an estimated ICER of £11,998/QALY. Sensitivity analysis indicated that only two parameters, seasonal variation in influenza B matching and influenza A circulation, had a substantial effect on the ICER. QIV would be likely to be cost-effective compared with TIV in 68% of simulations with a willingness-to-pay threshold of <£20,000/QALY and 87% with a willingness-to-pay threshold of <£30,000/QALY.

CONCLUSIONS

In this updated analysis, QIV was estimated to be cost-effective compared with TIV in the U.K.

Pesticide residues in urine of adults living in the United States: reference range concentrations

We measured 12 analytes in urine of 1000 adults living in the United States to establish reference range concentrations for pesticide residues. We frequently found six of these analytes: 2,5-dichlorophenol (in 98% of adults); 2,4-dichlorophenol (in 64%); 1-naphthol (in 86%); 2-naphthol (in 81%); 3,5,6- trichloro-2-pyridinol (in 82%); and pentachlorophenol (in 64%). The 95th percentile concentration (95th PC) for 2,5-dichlorophenol (indicative of p-dichlorobenzene exposure) was 790 micrograms/liter; concentrations ranged up to 8700 micrograms/liter. 2,4-Dichlorophenol concentrations ranged up to 450 micrograms/ liter, and the 95thPC was 64 micrograms/liter. 1-Naphthol and 2-naphthol (indicative of naphthalene exposure) had 95thPCs of 43 and 30 micrograms/liter, respectively; concentrations of 1-naphthol ranged up to 2500 micrograms/liter. Chlorpyrifos exposure was indicated by 3,5,6-tricholoro-2-pyridinol concentrations of 13 (95thPC) and 77 micrograms/liter (maximum observed). Pentachlorophenol had a 95thPC of 8.2 micrograms/liter. Other analytes measured included 4-nitrophenol (in 41%); 2,4,5-trichlorophenol (in 20%); 2,4,6-trichlorophenol (in 9.5%); 2,4-dichlorophenoxyacetic acid (in 12%); 2-isopropoxyphenol (in 6.8%); and 7-carbofuranphenol (in 1.5%). The 95thPCs of these analytes were < 6 micrograms/liter. p-Dichlorobenzene exposure is ubiquitous; naphthalene and chlorpyrifos are also major sources of pesticide exposure. Exposure to chlorpyrifos appears to be increasing. Although pentachlorophenol exposure is frequent, exposure appears to be decreasing. These reference range concentrations provide information about pesticide exposure and serve as a basis against which to compare concentrations in subjects who may have been exposed to pesticides.

Determination of pesticide metabolites in human urine using an isotope dilution technique and tandem mass spectrometry

A method that measures 12 analytes in urine and reflects possible exposure to pesticides was developed. The sample preparation involves enzyme hydrolysis and solvent extraction through the use of laboratory robotics, followed by phase-transfer catalysis derivatization and silica cleanup. Samples are analyzed by capillary gas chromatography and tandem mass spectrometry using an isotope dilution technique with 13C-labeled internal standards. The limit of detection is 1 microgram/L (1 part per billion) for most analytes, and most analytes have a linear response up to 100 micrograms/L. The precision of the method is reflected in the variation observed in quality control materials over 33 months; the variation averaged 17% for these analytes. On the basis of the detectable analyte levels of unspiked urine samples collected from unexposed volunteers, this method can be used to measure the low levels necessary for establishing reference range values of the selected pesticides or metabolites.

Anterior sternal retraction for reoperative median sternotomy

The incidence of reoperative median sternotomy for repeat cardiac surgery is increasing. Reoperative median sternotomy is associated with a higher morbidity and mortality than first-time cardiac surgery. A portion of this morbidity and mortality may be due to direct injury to the heart and great vessels in the process of reopening the sternum. We report a new technique utilizing anterior sternal retraction that allows division of adhesions between the undersurface of the sternum and the heart and great vessels under direct vision. This technique enables the surgeon to minimize the risk of serious injury to these underlying structures during reoperative cardiac surgery.

Evaluation of virus neutralization antibody levels in diabetic mutant mice

Experiments were designed to determine whether genetic predisposition to diabetes or overt diabetes in the identical genotype had an effect on the level of neutralization antibodies to coxsackievirus B4 (CB4). Quantitation of neutralization antibody (NT) levels against CB4 was performed using both the 50% endpoint procedure and the multivariate Wilcoxon rank sum test. The results of these experiments demonstrate that the use of the multivariate procedure for the analysis of neutralization antibody levels provides both quantitative and qualitative information not evident when only the classical 50% end point procedure is used. Moreover, when comparison on antibody levels between different groups is being considered, the power of the comparison is markedly greater using the multivariate Wilcoxon rank sum test results. The present report provide an illustration of the difference in the qualitative and quantitative information obtained by the end-point procedure and the more comprehensive multivariate procedure for the analysis of neutralization antibody levels in diabetic mutant mice infected with coxsackievirus B4.

Novel intrapulmonary model for orthotopic propagation of human lung cancers in athymic nude mice

A major impediment to the study of human lung cancer pathophysiology, as well as to the discovery and development of new specific antitumor agents for the treatment of lung cancer, has been the lack of appropriate experimental animal models. This paper describes a new model for the propagation of human lung tumor cells in the bronchioalveolar regions of the right lungs of athymic NCr-nu/nu mice via an intrabronchial (i.b.) implantation procedure. Over 1000 i.b. implantations have been performed to date, each requiring 3 to 5 min for completion and having a surgery-related mortality of approximately 5%. The model was used successfully for the orthotopic propagation of four established human lung cancer cell lines including: an adenosquamous cell carcinoma (NCI-H125); an adenocarcinoma (A549); a large cell undifferentiated carcinoma (NCI-H460), and a bronchioloalveolar cell carcinoma (NCI-H358). When each of the four cell lines was implanted i.b. using a 1.0 X 10(6) tumor cell inoculum, 100 +/- 0% (SD) tumor-related mortality was observed within 9 to 61 days. In contrast, when the conventional s.c. method for implantation was used at the same tumor cell inoculum, only minimal (2.5 +/- 5%) tumor-related mortality was observed within 140 days (P less than 0.001). Similarly, when a 1.0 X 10(5) or 1.0 X 10(4) cell inoculum was used, a dose-dependent, tumor-related mortality was observed when cells were implanted i.b. (56 +/- 24% or 25 +/- 17%) as compared with the s.c. method (5 +/- 5.7% or 0.0 +/- 0%) (P less than 0.02 and P less than 0.05, respectively). Most (greater than 90%) of the lung tumors propagated by i.b. implantation were localized to the right lung fields as documented by necropsy and/or high-resolution chest roentgenography techniques which were developed for these studies. The intrapulmonary model was also used for establishment and propagation of xenografts derived directly from enzymatically digested, fresh human lung tumor specimens obtained at the time of diagnostic thoracotomy and representing all four major lung cancer cell types as well as a bronchioloalveolar cell carcinoma. Approximately 35% (10 of 29) of the fresh primary human lung tumor specimens and 66% (2 of 3) of tumors metastatic to the lung were successfully propagated i.b. at a 1.0 X 10(6) tumor cell inoculum, whereas only 20% (1 of 5) of the specimens were successfully grown in vivo via the s.c. route from a 1.0 X 10(7) tumor cell inoculum.(ABSTRACT TRUNCATED AT 400 WORDS)

Sequential pathological changes induced in rats with the anti-cancer drug I, 3-bis (2-chloroethyl)-I-nitrosourea (BCNU)

The pathology of pulmonary toxicity induced by the anticancer drug 1, 3-bis(2-chloroethyl)-1-nitrosourea (BCNU) was studied in F344 rats. The compound was administered in a multiple-dose regimen comparable to the dose schedule commonly given patients. Morphological aspects were investigated by light and electron microscopy in a serial sacrifice experiment. All animals developed pulmonary fibrosis accompanied by formation of peribronchial and peribronchiolar foci of granulomatous tissue. The first morphologically detectable changes were identified in alveolar type II cells and were suggestive of disturbed surfactant synthesis. Endothelial damage accompanied by pronounced plasma cell infiltration developed subsequently and was followed by the development of diffuse interstitial fibrosis.

Sequential morphologic changes during methapyrilene-induced hepatocellular carcinogenesis in rats

The pathogenesis of hepatocellular tumors induced in F344 rats by the antihistaminic methapyrilene was investigated by light and electron microscopy in a serial sacrifice study. Eosinophilic foci of altered hepatocytes were found in portal areas after 1 week of treatment, the eosinophilia being caused by proliferation of mitochondria. Eosinophilic neoplastic nodules developed from such lesions after 16 weeks of treatment. Hepatocellular carcinomas developed after 26 weeks of treatment. Mitochondrial proliferation, which had been found as a marker for hepatocytes altered by this compound at 1 week of treatment, was still present in the hepatocellular carcinomas, which therefore met the morphologic criteria of oncocytomas.

Ultrastructure of nitrosoheptamethyleneimine-induced lung tumours in Fischer rats

Male F344 rats were given N-nitrosoheptamethyleneimine (NHMI) twice a week by gavage for 20 weeks. They developed peripheral squamous cell carcinomas of the lungs. Electron microscopy revealed the presence of mature keratin in the tumor centers and the formation of keratohyalin granules in the more peripheral tumor cells. Basal cells were identified as the actively growing component of the neoplasms. In contrast to NHMI-induced lung carcinomas in European hamsters, neither Clara, nor APUD-type, cells were found in the rat tumors. These data indicate that the mode of development of NHMI-induced lung tumors is different in these two species.

Sensitivity and specificity of virion and cell surface labeling using the unlabeled antibody-hemocyanin bridge method

The sensitivity and specificity of the unlabeled antibody-hemocyanin bridge method for immunoelectron microscopic localization of virion and cell surface antigens has been demonstrated using a hyperimmune serum to the Rauscher murine leukemia virus structural envelope glycoprotein (gp 70). The technique localized the gp70 on the viral envelope and on the infected cell surface at dilutions of greater than 10(-3) for the primary antiviral serum. Little or no nonspecific binding of hemocyanin was detected in control experiments using high concentrations of normal nonreacting or adequately absorbed antiviral primary sera and excess antibody bridge and marker; thus, the system is highly specific. Furthermore, sensitivity can be increased approximately fivefold by marked amplification steps whereby a specimen fixing only a slight amount of hemocyanin can be subsequently treated with antihemocyanin antibody, followed by hemocyanin.

Squirrel monkey retrovirus: electron microscopy of a virus from New World monkeys and comparison with Mason-Pfizer monkey virus

The ultrastructural morphogenesis of squirrel monkey retrovirus (SMRV) and Mason-Pfizer monkey virus (MPMV) growth in cell culture were compared. Both viruses develop by a process that begins with the formation of intracytoplasmic A particles which are then enveloped at the plasma membrane during budding. SMRV also develops as a crescent-shaped nucleoid beneath a bulging plasma membrane, a development characteristic of type C oncornaviruses. Free extra-cellular mature SMRV was generally round with a centrally located electron-dense nucleoid enclosed by the viral envelope. In contrast, mature MPMV had a tubular-shaped nucleoid. Negative stained preparations of both viruses yielded head-tail forms with surface projections. By uranyl acetate/critical point drying, SMRV particles were usually round with an eccentric electron-dense nucleoid enclosed by the viral envelope, whereas MPMV particles were round and contained an electron-dense bar-shaped nucleoid. These morphological observations indicate that SMRV more closely resembles MPMV, presently the only member of genus oncornavirus type D, than other retroviruses species. However, since SMRV can be morphologically, biochemically, and immunologically distinguished from MPMV, it represents a new species within genus oncornavirus type D.