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Weyant C, Hooda Y, Munira SJ, Lo NC, Ryckman T, Tanmoy AM, Kanon N, Seidman JC, Garrett D, Saha SK, Goldhaber-Fiebert JD, Saha S, Andrews JR. Cost-effectiveness and public health impact of typhoid conjugate vaccine introduction strategies in Bangladesh. Vaccine 2024; 42:2867-2876. [PMID: 38531727 PMCID: PMC11033679 DOI: 10.1016/j.vaccine.2024.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 03/13/2024] [Accepted: 03/14/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE Typhoid fever causes substantial morbidity and mortality in Bangladesh. The government of Bangladesh plans to introduce typhoid conjugate vaccines (TCV) in its expanded program on immunization (EPI) schedule. However, the optimal introduction strategy in addition to the costs and benefits of such a program are unclear. METHODS We extended an existing mathematical model of typhoid transmission to integrate cost data, clinical incidence data, and recently conducted serosurveys in urban, semi-urban, and rural areas. In our primary analysis, we evaluated the status quo (i.e., no vaccination) and eight vaccine introduction strategies including routine and 1-time campaign strategies, which differed by age groups targeted and geographic focus. Model outcomes included clinical incidence, seroincidence, deaths, costs, disability-adjusted life years (DALYs), and incremental cost-effectiveness ratios (ICERs) for each strategy. We adopted a societal perspective, 10-year model time horizon, and 3 % annual discount rate. We performed probabilistic, one-way, and scenario sensitivity analyses including adopting a healthcare perspective and alternate model time horizons. RESULTS We projected that all TCV strategies would be cost saving compared to the status quo. The preferred strategy was a nationwide introduction of TCV at 9-12 months of age with a single catch-up campaign for children ages 1-15, which was cost saving compared to all other strategies and the status quo. In the 10 years following implementation, we projected this strategy would avert 3.77 million cases (95 % CrI: 2.60 - 5.18), 11.31 thousand deaths (95 % CrI: 3.77 - 23.60), and save $172.35 million (95 % CrI: -14.29 - 460.59) compared to the status quo. Our findings were broadly robust to changes in parameter values and willingness-to-pay thresholds. CONCLUSIONS We projected that nationwide TCV introduction with a catch-up campaign would substantially reduce typhoid incidence and very likely be cost saving in Bangladesh.
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Affiliation(s)
- Christopher Weyant
- Department of Health Policy and Center for Health Policy, Stanford School of Medicine and Freeman Spogli Institute, Stanford University, Stanford, CA, United States.
| | - Yogesh Hooda
- Child Health Research Foundation, Dhaka, Bangladesh
| | | | - Nathan C Lo
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, CA, United States
| | - Theresa Ryckman
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States
| | | | - Naito Kanon
- Child Health Research Foundation, Dhaka, Bangladesh
| | | | | | - Samir K Saha
- Child Health Research Foundation, Dhaka, Bangladesh; Department of Microbiology, Bangladesh Shishu Hospital and Institute, Dhaka, Bangladesh
| | - Jeremy D Goldhaber-Fiebert
- Department of Health Policy and Center for Health Policy, Stanford School of Medicine and Freeman Spogli Institute, Stanford University, Stanford, CA, United States
| | - Senjuti Saha
- Child Health Research Foundation, Dhaka, Bangladesh
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University, Stanford, CA, United States
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Ryckman T, Codjia P, Nordhagen S, Arimi C, Kirogo V, Kiige L, Kamudoni P, Beal T. A subnational affordability assessment of nutritious foods for complementary feeding in Kenya. Matern Child Nutr 2024; 20 Suppl 3:e13373. [PMID: 35666006 PMCID: PMC10782139 DOI: 10.1111/mcn.13373] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 04/17/2022] [Accepted: 04/26/2022] [Indexed: 06/15/2023]
Abstract
Complementary feeding among children aged 6-23 months is a key determinant of micronutrient deficiencies and childhood stunting, the burdens of which remain high in Kenya. This study examines the affordability of complementary foods to increase young children's nutrient consumption across eight provinces in Kenya. We combined data from household surveys, food composition tables and published sources to estimate the cost of portion sizes that could meet half of the children's daily iron, vitamin A, calcium, zinc, folate, vitamin B12 and protein requirements from complementary feeding. These costs were compared to current household food expenditures. The selection of foods and price and expenditure data were stratified by province. Our analysis indicates that vitamin A, vitamin B12 and folate are affordable to most households in Kenya via liver, beans and in some provinces, orange-fleshed fruits and vegetables, avocado and small dried fish. Calcium, animal-source protein, zinc and iron were less affordable and there was more provincial variation. In some provinces, small dried fish were an affordable source of calcium, protein and zinc. In others (North Eastern, Central, Eastern, parts of Rift Valley and Coast), small dried fish were not commonly consumed and other foods were less affordable. Future research should consider interventions aimed at reducing prices, increasing availability and changing behaviours related to these foods. Solutions such as supplementation and fortification may be needed for iron and zinc in some locations. Food affordability presented the greatest barriers in North Eastern province, which had lower dietary diversity and may require additional targeted interventions.
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Affiliation(s)
- Theresa Ryckman
- Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | | | | | - Caroline Arimi
- Division of Nutrition and DieteticsMinistry of HealthNairobiKenya
| | - Veronica Kirogo
- Division of Nutrition and DieteticsMinistry of HealthNairobiKenya
| | | | | | - Ty Beal
- Global Alliance for Improved Nutrition (GAIN)WashingtonDCUSA
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Reid M, Agbassi YJP, Arinaminpathy N, Bercasio A, Bhargava A, Bhargava M, Bloom A, Cattamanchi A, Chaisson R, Chin D, Churchyard G, Cox H, Denkinger CM, Ditiu L, Dowdy D, Dybul M, Fauci A, Fedaku E, Gidado M, Harrington M, Hauser J, Heitkamp P, Herbert N, Herna Sari A, Hopewell P, Kendall E, Khan A, Kim A, Koek I, Kondratyuk S, Krishnan N, Ku CC, Lessem E, McConnell EV, Nahid P, Oliver M, Pai M, Raviglione M, Ryckman T, Schäferhoff M, Silva S, Small P, Stallworthy G, Temesgen Z, van Weezenbeek K, Vassall A, Velásquez GE, Venkatesan N, Yamey G, Zimmerman A, Jamison D, Swaminathan S, Goosby E. Scientific advances and the end of tuberculosis: a report from the Lancet Commission on Tuberculosis. Lancet 2023; 402:1473-1498. [PMID: 37716363 DOI: 10.1016/s0140-6736(23)01379-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 06/14/2023] [Accepted: 06/29/2023] [Indexed: 09/18/2023]
Affiliation(s)
- Michael Reid
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA.
| | - Yvan Jean Patrick Agbassi
- Global TB Community Advisory Board, Abidjan, Côte d'Ivoire, Yenepoya Medical College, Mangalore, India
| | | | - Alyssa Bercasio
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Anurag Bhargava
- Department of General Medicine, Yenepoya Medical College, Mangalore, India
| | - Madhavi Bhargava
- Department of Community Medicine, Yenepoya Medical College, Mangalore, India
| | - Amy Bloom
- Division of Tuberculosis, Bureau of Global Health, USAID, Washington, DC, USA
| | | | - Richard Chaisson
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel Chin
- Bill and Melinda Gates Foundation, Seattle, WA, USA
| | | | - Helen Cox
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Claudia M Denkinger
- Heidelberg University Hospital, German Center of Infection Research, Heidelberg, Germany
| | | | - David Dowdy
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Mark Dybul
- Department of Medicine, Center for Global Health Practice and Impact, Georgetown University, Washington, DC, USA
| | - Anthony Fauci
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | | | | | | | - Petra Heitkamp
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Nick Herbert
- Global TB Caucus, Houses of Parliament, London, UK
| | | | - Philip Hopewell
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Emily Kendall
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Aamir Khan
- Interactive Research & Development, Karachi, Pakistan
| | - Andrew Kim
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Nalini Krishnan
- Resource Group for Education and Advocacy for Community Health (REACH), Chennai, India
| | - Chu-Chang Ku
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
| | - Erica Lessem
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | - Payam Nahid
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | | | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Mario Raviglione
- Centre for Multidisciplinary Research in Health Science, University of Milan, Milan, Italy
| | - Theresa Ryckman
- Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Sachin Silva
- Harvard TH Chan School of Public Health, Harvard University, Cambridge, MA, USA
| | | | | | | | | | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Gustavo E Velásquez
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | | | - Gavin Yamey
- Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, NC, USA
| | | | - Dean Jamison
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | | | - Eric Goosby
- University of California San Francisco Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
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Ryckman T, Weiser J, Gombe M, Turner K, Soni P, Tarlton D, Mazhidova N, Churchyard G, Chaisson RE, Dowdy DW. Impact and cost-effectiveness of short-course tuberculosis preventive treatment for household contacts and people with HIV in 29 high-incidence countries: a modelling analysis. Lancet Glob Health 2023; 11:e1205-e1216. [PMID: 37474228 PMCID: PMC10369017 DOI: 10.1016/s2214-109x(23)00251-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Guidelines and implementation of tuberculosis preventive treatment (TPT) vary by age and HIV status. Specifically, TPT is strongly recommended for people living with HIV/AIDS (PLWHA) and household contacts younger than 5 years but only conditionally recommended for older contacts. Cost remains a major barrier to implementation. The aim of this study was to evaluate the cost-effectiveness of TPT for household contacts and PLWHA. METHODS We developed a state-transition model to simulate short-course TPT for household contacts and PLWHA in 29 high-incidence countries based on data from previous studies and public databases. Our primary outcome was the incremental cost-effectiveness ratio, expressed as incremental discounted costs (2020 US$, including contact investigation costs) per incremental discounted disability-adjusted life year (DALY) averted, compared with a scenario without any TPT or contact investigation. We propagated uncertainty in all model parameters using probabilistic sensitivity analysis and also evaluated the sensitivity of results to the screening algorithm used to rule out active disease, the choice of TPT regimen, the modelling time horizon, assumptions about TPT coverage, antiretroviral therapy discontinuation, and secondary transmission. FINDINGS Between 2023 and 2035, scaling up TPT prevented 0·9 (95% uncertainty interval 0·4-1·6) people from developing tuberculosis and 0·13 (0·05-0·27) tuberculosis deaths per 100 PLWHA, at an incremental cost of $15 (9-21) per PLWHA. For household contacts, TPT (with contact investigation) averted 1·1 (0·5-2·0) cases and 0·7 (0·4-1·0) deaths per 100 contacts, at a cost of $21 (17-25) per contact. Cost-effectiveness was most favourable for household contacts younger than 5 years ($22 per DALY averted) and contacts aged 5-14 years ($104 per DALY averted) but also fell within conservative cost-effectiveness thresholds in many countries for PLWHA ($722 per DALY averted) and adult contacts ($309 per DALY averted). Costs per DALY averted tended to be lower when compared with a scenario with contact investigation but no TPT. The cost-effectiveness of TPT was not substantially altered in sensitivity analyses, except that TPT was more favourable in analysis that considered a longer time horizon or included secondary transmission benefits. INTERPRETATION In many high-incidence countries, short-course TPT is likely to be cost-effective for PLWHA and household contacts of all ages, regardless of whether contact investigation is already in place. Failing to implement tuberculosis contact investigation and TPT will incur a large burden of avertable illness and mortality in the next decade. FUNDING Unitaid.
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Affiliation(s)
- Theresa Ryckman
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Jeff Weiser
- The Aurum Institute, Parktown, Johannesburg, South Africa
| | - Makaita Gombe
- The Aurum Institute, Parktown, Johannesburg, South Africa
| | - Karin Turner
- The Aurum Institute, Parktown, Johannesburg, South Africa
| | | | | | | | | | - Richard E Chaisson
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David W Dowdy
- Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Ryckman T, Robsky K, Cilloni L, Zawedde-Muyanja S, Ananthakrishnan R, Kendall EA, Shrestha S, Turyahabwe S, Katamba A, Dowdy DW. Ending tuberculosis in a post-COVID-19 world: a person-centred, equity-oriented approach. Lancet Infect Dis 2023; 23:e59-e66. [PMID: 35963272 PMCID: PMC9365311 DOI: 10.1016/s1473-3099(22)00500-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 02/02/2023]
Abstract
The COVID-19 pandemic has disrupted systems of care for infectious diseases-including tuberculosis-and has exposed pervasive inequities that have long marred efforts to combat these diseases. The resulting health disparities often intersect at the individual and community levels in ways that heighten vulnerability to tuberculosis. Effective responses to tuberculosis (and other infectious diseases) must respond to these realities. Unfortunately, current tuberculosis programmes are generally not designed from the perspectives of affected individuals and fail to address structural determinants of health disparities. We describe a person-centred, equity-oriented response that would identify and focus on communities affected by disparities, tailor interventions to the mechanisms by which disparities worsen tuberculosis, and address upstream determinants of those disparities. We detail four key elements of the approach (data collection, programme design, implementation, and sustainability). We then illustrate how organisations at multiple levels might partner and adapt current practices to incorporate these elements. Such an approach could generate more substantial, sustainable, and equitable reductions in tuberculosis burden at the community level, highlighting the urgency of restructuring post-COVID-19 health systems in a more person-centred, equity-oriented way.
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Affiliation(s)
- Theresa Ryckman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Katherine Robsky
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Lucia Cilloni
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stella Zawedde-Muyanja
- The Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Emily A Kendall
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sourya Shrestha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Clinical Epidemiology and Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Center for Tuberculosis Research, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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6
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Burrows H, Antillón M, Gauld JS, Kim JH, Mogasale V, Ryckman T, Andrews JR, Lo NC, Pitzer VE. Comparison of model predictions of typhoid conjugate vaccine public health impact and cost-effectiveness. Vaccine 2023; 41:965-975. [PMID: 36586741 PMCID: PMC9880559 DOI: 10.1016/j.vaccine.2022.12.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/31/2022]
Abstract
Models are useful to inform policy decisions on typhoid conjugate vaccine (TCV) deployment in endemic settings. However, methodological choices can influence model-predicted outcomes. To provide robust estimates for the potential public health impact of TCVs that account for structural model differences, we compared four dynamic and one static mathematical model of typhoid transmission and vaccine impact. All models were fitted to a common dataset of age-specific typhoid fever cases in Kolkata, India. We evaluated three TCV strategies: no vaccination, routine vaccination at 9 months of age, and routine vaccination at 9 months with a one-time catch-up campaign (ages 9 months to 15 years). The primary outcome was the predicted percent reduction in symptomatic typhoid cases over 10 years after vaccine introduction. For three models with economic analyses (Models A-C), we also compared the incremental cost-effectiveness ratios (ICERs), calculated as the incremental cost (US$) per disability-adjusted life-year (DALY) averted. Routine vaccination was predicted to reduce symptomatic cases by 10-46 % over a 10-year time horizon under an optimistic scenario (95 % initial vaccine efficacy and 19-year mean duration of protection), and by 2-16 % under a pessimistic scenario (82 % initial efficacy and 6-year mean protection). Adding a catch-up campaign predicted a reduction in incidence of 36-90 % and 6-35 % in the optimistic and pessimistic scenarios, respectively. Vaccine impact was predicted to decrease as the relative contribution of chronic carriers to transmission increased. Models A-C all predicted routine vaccination with or without a catch-up campaign to be cost-effective compared to no vaccination, with ICERs varying from $95-789 per DALY averted; two models predicted the ICER of routine vaccination alone to be greater than with the addition of catch-up campaign. Despite differences in model-predicted vaccine impact and cost-effectiveness, routine vaccination plus a catch-up campaign is likely to be impactful and cost-effective in high incidence settings such as Kolkata.
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Affiliation(s)
- Holly Burrows
- Yale School of Public Health, Yale University, New Haven, CT, USA.
| | - Marina Antillón
- Yale School of Public Health, Yale University, New Haven, CT, USA; Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Jillian S Gauld
- Institute for Disease Modeling, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Jong-Hoon Kim
- Public Health, Access, and Vaccine Epidemiology (PAVE) Unit, International Vaccine Institute, Seoul, Republic of Korea
| | - Vittal Mogasale
- Policy and Economic Research Department, International Vaccine Institute, Seoul 08826, Republic of Korea
| | - Theresa Ryckman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Nathan C Lo
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, CA, USA
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7
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Ryckman T, Karthikeyan AS, Kumar D, Cao Y, Kang G, Goldhaber-Fiebert JD, John J, Lo NC, Andrews JR. Comparison of Strategies for Typhoid Conjugate Vaccine Introduction in India: A Cost-Effectiveness Modeling Study. J Infect Dis 2021; 224:S612-S624. [PMID: 35238367 PMCID: PMC8892534 DOI: 10.1093/infdis/jiab150] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Typhoid fever causes substantial global mortality, with almost half occurring in India. New typhoid vaccines are highly effective and recommended by the World Health Organization for high-burden settings. There is a need to determine whether and which typhoid vaccine strategies should be implemented in India. Methods We assessed typhoid vaccination using a dynamic compartmental model, parameterized by and calibrated to disease and costing data from a recent multisite surveillance study in India. We modeled routine and 1-time campaign strategies that target different ages and settings. The primary outcome was cost-effectiveness, measured by incremental cost-effectiveness ratios (ICERs) benchmarked against India’s gross national income per capita (US$2130). Results Both routine and campaign vaccination strategies were cost-saving compared to the status quo, due to averted costs of illness. The preferred strategy was a nationwide community-based catchup campaign targeting children aged 1–15 years alongside routine vaccination, with an ICER of $929 per disability-adjusted life-year averted. Over the first 10 years of implementation, vaccination could avert 21–39 million cases and save $1.6–$2.2 billion. These findings were broadly consistent across willingness-to-pay thresholds, epidemiologic settings, and model input distributions. Conclusions Despite high initial costs, routine and campaign typhoid vaccination in India could substantially reduce mortality and was highly cost-effective.
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Affiliation(s)
- Theresa Ryckman
- Stanford Health Policy, Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine and the Freeman Spogli Institute, Stanford, California, USA
| | - Arun S Karthikeyan
- Wellcome Trust Research Laboratory, Christian Medical College, Vellore, Tamil Nadu, India
| | - Dilesh Kumar
- Wellcome Trust Research Laboratory, Christian Medical College, Vellore, Tamil Nadu, India
| | - Yanjia Cao
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Gagandeep Kang
- Wellcome Trust Research Laboratory, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University School of Medicine and the Freeman Spogli Institute, Stanford, California, USA
| | - Jacob John
- Department of Community Health, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nathan C Lo
- Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
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8
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Cao Y, Karthikeyan AS, Ramanujam K, Raju R, Krishna S, Kumar D, Ryckman T, Mohan VR, Kang G, John J, Andrews JR, Lo NC. Geographic Pattern of Typhoid Fever in India: A Model-Based Estimate of Cohort and Surveillance Data. J Infect Dis 2021; 224:S475-S483. [PMID: 35238365 PMCID: PMC8892532 DOI: 10.1093/infdis/jiab187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Typhoid fever remains a major public health problem in India. Recently, the Surveillance for Enteric Fever in India program completed a multisite surveillance study. However, data on subnational variation in typhoid fever are needed to guide the introduction of the new typhoid conjugate vaccine in India.
Methods
We applied a geospatial statistical model to estimate typhoid fever incidence across India, using data from 4 cohort studies and 6 hybrid surveillance sites from October 2017 to March 2020. We collected geocoded data from the Demographic and Health Survey in India as predictors of typhoid fever incidence. We used a log linear regression model to predict a primary outcome of typhoid incidence.
Results
We estimated a national incidence of typhoid fever in India of 360 cases (95% confidence interval [CI], 297–494) per 100 000 person-years, with an annual estimate of 4.5 million cases (95% CI, 3.7–6.1 million) and 8930 deaths (95% CI, 7360–12 260), assuming a 0.2% case-fatality rate. We found substantial geographic variation of typhoid incidence across the country, with higher incidence in southwestern states and urban centers in the north.
Conclusions
There is a large burden of typhoid fever in India with substantial heterogeneity across the country, with higher burden in urban centers.
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Affiliation(s)
- Yanjia Cao
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | | | | | - Reshma Raju
- Wellcome Research Unit, Christian Medical College, Vellore, India
| | - Swathi Krishna
- Wellcome Research Unit, Christian Medical College, Vellore, India
| | - Dilesh Kumar
- Wellcome Research Unit, Christian Medical College, Vellore, India
| | - Theresa Ryckman
- Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University School of Medicine, Stanford, California, USA
| | | | - Gagandeep Kang
- Wellcome Research Unit, Christian Medical College, Vellore, India
| | - Jacob John
- Department of Community Health, Christian Medical College, Vellore, India
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Nathan C Lo
- Deparment of Medicine, University of California, San Francisco, San Francisco, California, USA
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9
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Ryckman T, Chin ET, Prince L, Leidner D, Long E, Studdert DM, Salomon JA, Alarid-Escudero F, Andrews JR, Goldhaber-Fiebert JD. Outbreaks of COVID-19 variants in US prisons: a mathematical modelling analysis of vaccination and reopening policies. Lancet Public Health 2021; 6:e760-e770. [PMID: 34364404 PMCID: PMC8342313 DOI: 10.1016/s2468-2667(21)00162-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Residents of prisons have experienced disproportionate COVID-19-related health harms. To control outbreaks, many prisons in the USA restricted in-person activities, which are now resuming even as viral variants proliferate. This study aims to use mathematical modelling to assess the risks and harms of COVID-19 outbreaks in prisons under a range of policies, including resumption of activities. METHODS We obtained daily resident-level data for all California state prisons from Jan 1, 2020, to May 15, 2021, describing prison layouts, housing status, sociodemographic and health characteristics, participation in activities, and COVID-19 testing, infection, and vaccination status. We developed a transmission-dynamic stochastic microsimulation parameterised by the California data and published literature. After an initial infection is introduced to a prison, the model evaluates the effect of various policy scenarios on infections and hospitalisations over 200 days. Scenarios vary by vaccine coverage, baseline immunity (0%, 25%, or 50%), resumption of activities, and use of non-pharmaceutical interventions (NPIs) that reduce transmission by 75%. We simulated five prison types that differ by residential layout and demographics, and estimated outcomes with and without repeated infection introductions over the 200 days. FINDINGS If a viral variant is introduced into a prison that has resumed pre-2020 contact levels, has moderate vaccine coverage (ranging from 36% to 76% among residents, dependent on age, with 40% coverage for staff), and has no baseline immunity, 23-74% of residents are expected to be infected over 200 days. High vaccination coverage (90%) coupled with NPIs reduces cumulative infections to 2-54%. Even in prisons with low room occupancies (ie, no more than two occupants) and low levels of cumulative infections (ie, <10%), hospitalisation risks are substantial when these prisons house medically vulnerable populations. Risks of large outbreaks (>20% of residents infected) are substantially higher if infections are repeatedly introduced. INTERPRETATION Balancing benefits of resuming activities against risks of outbreaks presents challenging trade-offs. After achieving high vaccine coverage, prisons with mostly one-to-two-person cells that have higher baseline immunity from previous outbreaks can resume in-person activities with low risk of a widespread new outbreak, provided they maintain widespread NPIs, continue testing, and take measures to protect the medically vulnerable. FUNDING Horowitz Family Foundation, National Institute on Drug Abuse, Centers for Disease Control and Prevention, National Science Foundation, Open Society Foundation, Advanced Micro Devices.
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Affiliation(s)
- Theresa Ryckman
- Stanford Health Policy, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Elizabeth T Chin
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Lea Prince
- Stanford Health Policy, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - David Leidner
- California Department of Corrections and Rehabilitation, Elk Grove, CA, USA
| | - Elizabeth Long
- Stanford Health Policy, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - David M Studdert
- Stanford Health Policy, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA; Stanford Law School, Stanford, CA, USA
| | - Joshua A Salomon
- Stanford Health Policy, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Fernando Alarid-Escudero
- Division of Public Administration, Center for Research and Teaching in Economics, Aguascalientes, Mexico
| | - Jason R Andrews
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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10
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Chin ET, Ryckman T, Prince L, Leidner D, Alarid-Escudero F, Andrews JR, Salomon JA, Studdert DM, Goldhaber-Fiebert JD. COVID-19 in the California State Prison System: an Observational Study of Decarceration, Ongoing Risks, and Risk Factors. J Gen Intern Med 2021; 36:3096-3102. [PMID: 34291377 PMCID: PMC8294831 DOI: 10.1007/s11606-021-07022-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/30/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Correctional institutions nationwide are seeking to mitigate COVID-19-related risks. OBJECTIVE To quantify changes to California's prison population since the pandemic began and identify risk factors for COVID-19 infection. DESIGN For California state prisons (March 1-October 10, 2020), we described residents' demographic characteristics, health status, COVID-19 risk scores, room occupancy, and labor participation. We used Cox proportional hazard models to estimate the association between rates of COVID-19 infection and room occupancy and out-of-room labor, respectively. PARTICIPANTS Residents of California state prisons. MAIN MEASURES Changes in the incarcerated population's size, composition, housing, and activities. For the risk factor analysis, the exposure variables were room type (cells vs. dormitories) and labor participation (any room occupant participating in the prior 2 weeks) and the outcome variable was incident COVID-19 case rates. KEY RESULTS The incarcerated population decreased 19.1% (119,401 to 96,623) during the study period. On October 10, 2020, 11.5% of residents were aged ≥60, 18.3% had high COVID-19 risk scores, 31.0% participated in out-of-room labor, and 14.8% lived in rooms with ≥10 occupants. Nearly 40% of residents with high COVID-19 risk scores lived in dormitories. In 9 prisons with major outbreaks (6,928 rooms; 21,750 residents), dormitory residents had higher infection rates than cell residents (adjusted hazard ratio [AHR], 2.51 95% CI, 2.25-2.80) and residents of rooms with labor participation had higher rates than residents of other rooms (AHR, 1.56; 95% CI, 1.39-1.74). CONCLUSION Despite reductions in room occupancy and mixing, California prisons still house many medically vulnerable residents in risky settings. Reducing risks further requires a combination of strategies, including rehousing, decarceration, and vaccination.
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Affiliation(s)
- Elizabeth T Chin
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Theresa Ryckman
- Stanford Health Policy and the Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lea Prince
- Stanford Health Policy and the Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Fernando Alarid-Escudero
- Division of Public Administration, Center for Research and Teaching in Economics (CIDE), Aguascalientes, Aguascalientes, Mexico
| | - Jason R Andrews
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Joshua A Salomon
- Stanford Health Policy and the Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - David M Studdert
- Stanford Health Policy and the Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Law School, Stanford, CA, USA
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy and the Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
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Chin ET, Leidner D, Ryckman T, Liu YE, Prince L, Alarid-Escudero F, Andrews JR, Salomon JA, Goldhaber-Fiebert JD, Studdert DM. Covid-19 Vaccine Acceptance in California State Prisons. N Engl J Med 2021; 385:374-376. [PMID: 33979505 PMCID: PMC8133697 DOI: 10.1056/nejmc2105282] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | | | | | - Yiran E Liu
- Stanford University School of Medicine, Stanford, CA
| | - Lea Prince
- Stanford University School of Medicine, Stanford, CA
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Abstract
Low intake of diverse complementary foods causes critical nutrient gaps in the diets of young children. Inadequate nutrient intake in the first 2 years of life can lead to poor health, educational, and economic outcomes. In this study, the extent to which food affordability is a barrier to consumption of several nutrients critical for child growth and development was examined in Ethiopia, Mozambique, South Africa, Tanzania, Uganda, and Zambia. Drawing upon data from nutrient gap assessments, household surveys, and food composition tables, current consumption levels were assessed, the cost of purchasing key nutritious foods that could fill likely nutrient gaps was calculated, and these costs were compared with current household food expenditure. Vitamin A is affordable for most households (via dark leafy greens, orange-fleshed vegetables, and liver) but only a few foods (fish, legumes, dairy, dark leafy greens, liver) are affordable sources of iron, animal-source protein, or calcium, and only in some countries. Zinc is ubiquitously unaffordable. For unaffordable nutrients, approaches to reduce prices, enhance household production, or increase household resources for nutritious foods are needed.
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Affiliation(s)
- Theresa Ryckman
- Center for Health Policy and the Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Ty Beal
- Global Alliance for Improved Nutrition, Washington DC, USA
- Department of Environmental Science and Policy, University of California, Davis, Davis, California, USA
| | | | - Kudakwashe Chimanya
- United Nations Children’s Fund, Regional Office for Eastern and Southern Africa, Nairobi, Kenya
| | - Joan Matji
- United Nations Children’s Fund, Regional Office for Eastern and Southern Africa, Nairobi, Kenya
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13
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Abstract
The high prevalence of stunting and micronutrient deficiencies among children in South Asia has lifelong health, educational, and economic consequences. For children aged 6-23 months, undernutrition is influenced by inadequate intake of complementary foods containing nutrients critical for growth and development. The affordability of nutrients lacking in young children's diets in Bangladesh, India, and Pakistan was assessed in this study. Using data from nutrient gap assessments and household surveys, household food expenditures were compared with the cost of purchasing foods that could fill nutrient gaps. In all 3 countries, there are multiple affordable sources of vitamin A (orange-fleshed vegetables, dark leafy greens, liver), vitamin B12 (liver, fish, milk), and folate (dark leafy greens, liver, legumes, okra); few affordable sources of iron and calcium (dark leafy greens); and no affordable sources of zinc. Affordability of animal-source protein varies, with several options in Pakistan (fish, chicken, eggs, beef) and India (fish, eggs, milk) but few in Bangladesh (eggs). Approaches to reduce prices, enhance household production, or increase incomes are needed to improve affordability.
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Affiliation(s)
- Theresa Ryckman
- Center for Health Policy and the Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Ty Beal
- Global Alliance for Improved Nutrition, Washington, DC, USA
- Department of Environmental Science and Policy, University of California, Davis, Davis, California, USA
| | | | - Zivai Murira
- United Nations Children’s Fund, Regional Office for South Asia, Kathmandu, Nepal
| | - Harriet Torlesse
- United Nations Children’s Fund, Regional Office for South Asia, Kathmandu, Nepal
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14
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Chin ET, Ryckman T, Prince L, Leidner D, Alarid-Escudero F, Andrews JR, Salomon JA, Studdert DM, Goldhaber-Fiebert JD. Covid-19 in the California State Prison System: An Observational Study of Decarceration, Ongoing Risks, and Risk Factors. medRxiv 2021. [PMID: 33758868 PMCID: PMC7987024 DOI: 10.1101/2021.03.04.21252942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background: Correctional institutions nationwide are seeking to mitigate Covid-19-related risks. Objective: To quantify changes to California’s prison population since the pandemic began and identify risk factors for Covid-19 infection. Design: We described residents’ demographic characteristics, health status, Covid-19 risk scores, room occupancy, and labor participation. We used Cox proportional hazard models to estimate the association between rates of Covid-19 infection and room occupancy and out-of-room labor, respectively. Setting: California state prisons (March 1-October 10, 2020). Participants: Residents of California state prisons. Measurements: Changes in the incarcerated population’s size, composition, housing, and activities. For the risk factor analysis, the exposure variables were room type (cells vs dormitories) and labor participation (any room occupant participating in the prior 2 weeks) and the outcome variable was incident Covid-19 case rates. Results: The incarcerated population decreased 19.1% (119,401 to 96,623) during the study period. On October 10, 2020, 11.5% of residents were aged ≤60, 18.3% had high Covid-19 risk scores, 31.0% participated in out-of-room labor, and 14.8% lived in rooms with ≤10 occupants. Nearly 40% of residents with high Covid-19 risk scores lived in dormitories. In 9 prisons with major outbreaks (6,928 rooms; 21,750 residents), dormitory residents had higher infection rates than cell residents (adjusted hazard ratio [AHR], 2.51 95%CI, 2.25-2.80) and residents of rooms with labor participation had higher rates than residents of other rooms (AHR, 1.56; 95%CI, 1.39-1.74). Limitations: Inability to measure density of residents’ living conditions or contact networks among residents and staff. Conclusion: Despite reductions in room occupancy and mixing, California prisons still house many medically vulnerable residents in risky settings. Reducing risks further requires a combination of strategies, including rehousing, decarceration, and vaccination. Funding Sources: Horowitz Family Foundation; National Institute on Drug Abuse; National Science Foundation Graduate Research Fellowship; Open Society Foundations.
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Affiliation(s)
- Elizabeth T Chin
- Department of Biomedical Data Science, Stanford University, Stanford, CA, USA
| | - Theresa Ryckman
- Stanford Health Policy and the Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lea Prince
- Stanford Health Policy and the Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Fernando Alarid-Escudero
- Division of Public Administration, Center for Research and Teaching in Economics (CIDE), Aguascalientes, Aguascalientes, Mexico
| | - Jason R Andrews
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Joshua A Salomon
- Stanford Health Policy and the Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - David M Studdert
- Stanford Health Policy and the Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Law School, Stanford, CA, USA
| | - Jeremy D Goldhaber-Fiebert
- Stanford Health Policy and the Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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15
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Ryckman T, Luby S, Owens DK, Bendavid E, Goldhaber-Fiebert JD. Methods for Model Calibration under High Uncertainty: Modeling Cholera in Bangladesh. Med Decis Making 2020; 40:693-709. [PMID: 32639859 DOI: 10.1177/0272989x20938683] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background. Published data on a disease do not always correspond directly to the parameters needed to simulate natural history. Several calibration methods have been applied to computer-based disease models to extract needed parameters that make a model's output consistent with available data. Objective. To assess 3 calibration methods and evaluate their performance in a real-world application. Methods. We calibrated a model of cholera natural history in Bangladesh, where a lack of active surveillance biases available data. We built a cohort state-transition cholera natural history model that includes case hospitalization to reflect the passive surveillance data-generating process. We applied 3 calibration techniques: incremental mixture importance sampling, sampling importance resampling, and random search with rejection sampling. We adapted these techniques to the context of wide prior uncertainty and many degrees of freedom. We evaluated the resulting posterior parameter distributions using a range of metrics and compared predicted cholera burden estimates. Results. All 3 calibration techniques produced posterior distributions with a higher likelihood and better fit to calibration targets as compared with prior distributions. Incremental mixture importance sampling resulted in the highest likelihood and largest number of unique parameter sets to better inform joint parameter uncertainty. Compared with naïve uncalibrated parameter sets, calibrated models of cholera in Bangladesh project substantially more cases, many of which are not detected by passive surveillance, and fewer deaths. Limitations. Calibration cannot completely overcome poor data quality, which can leave some parameters less well informed than others. Calibration techniques may perform differently under different circumstances. Conclusions. Incremental mixture importance sampling, when adapted to the context of high uncertainty, performs well. By accounting for biases in data, calibration can improve model projections of disease burden.
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Affiliation(s)
- Theresa Ryckman
- Center for Health Policy and Center for Primary Care & Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephen Luby
- Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
| | - Douglas K Owens
- VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Center for Health Policy and Center for Primary Care & Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Eran Bendavid
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Center for Health Policy and Center for Primary Care & Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jeremy D Goldhaber-Fiebert
- Center for Health Policy and Center for Primary Care & Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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16
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Ryckman T, Robinson M, Pedersen C, Bhattacharya J, Bendavid E. Impact of Feed the Future initiative on nutrition in children aged less than 5 years in sub-Saharan Africa: difference-in-differences analysis. BMJ 2019; 367:l6540. [PMID: 31826875 PMCID: PMC7190055 DOI: 10.1136/bmj.l6540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the impact of the US government's Feed the Future initiative on nutrition outcomes in children younger than 5 years in sub-Saharan Africa. DESIGN Difference-in-differences quasi-experimental approach. SETTING Households in 33 low and lower middle income countries in sub-Saharan Africa. POPULATION 883 309 children aged less than 5 years with weight, height, and age recorded in 118 surveys conducted in 33 countries between 2000 and 2017: 388 052 children were from Feed the Future countries and 495 257 were from non-Feed the Future countries. MAIN OUTCOME MEASURES A difference-in-differences approach was used to compare outcomes among children in intervention countries after implementation of the initiative with children before its introduction and children in non-intervention countries, controlling for relevant covariates, time invariant national differences, and time trends. The primary outcome was stunting (height for age >2 standard deviations below a reference median), a key indicator of undernutrition in children. Secondary outcomes were wasting (low weight for height) and underweight (low weight for age). RESULTS Across all years and countries, 38.3% of children in the study sample were stunted, 8.9% showed wasting, and 21.3% were underweight. In the first six years of Feed the Future's implementation, children in 12 countries with the initiative exhibited a 3.9 percentage point (95% confidence interval 2.4 to 5.5) greater decline in stunting, a 1.1 percentage point (0.1 to 2.1) greater decline in wasting, and a 2.8 percentage point (1.6 to 4.0) greater decline in underweight levels compared with children in 21 countries without the initiative and compared with trends in undernutrition before Feed the Future was launched. These decreases translate to around two million fewer stunted and underweight children aged less than 5 years and around a half million fewer children with wasting. For context, about 22 million children were stunted, 11 million children were underweight, and four million children were wasted in the Feed the Future countries at baseline. CONCLUSIONS Feed the Future's activities were closely linked to notable improvements in stunting and underweight levels and moderate improvements in wasting in children younger than 5 years. These findings highlight the effectiveness of this large, country tailored initiative focused on agriculture and food security and have important implications for the future of this and other nutrition interventions worldwide.
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Affiliation(s)
- Theresa Ryckman
- Center for Health Policy and the Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - Jay Bhattacharya
- Center for Health Policy and the Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- National Bureau of Economic Research, Cambridge, MA, USA
| | - Eran Bendavid
- Center for Health Policy and the Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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17
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Kallenberg J, Mok W, Newman R, Nguyen A, Ryckman T, Saxenian H, Wilson P. Gavi's Transition Policy: Moving From Development Assistance To Domestic Financing Of Immunization Programs. Health Aff (Millwood) 2017; 35:250-8. [PMID: 26858377 DOI: 10.1377/hlthaff.2015.1079] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Gavi, the Vaccine Alliance, was created in 2000 to accelerate the introduction of new and underused vaccines in lower-income countries. The period 2000-15 was marked by the rapid uptake of new vaccines in more than seventy countries eligible for Gavi support. To stay focused on the poorest countries, Gavi's support phases out after countries' gross national income per capita surpasses a set threshold, which requires governments to assume responsibility for the continued financing of vaccines introduced with Gavi support. Gavi's funding will end in the period 2016-20 for nineteen countries that have exceeded the eligibility threshold. To avoid disrupting lifesaving immunization programs and to ensure the long-term sustainable impact of Gavi's investments, it is vital that governments succeed in transitioning from development assistance to domestic financing of immunization programs. This article discusses some of the challenges facing countries currently transitioning out of Gavi support, how Gavi's policies have evolved to help manage the risks involved in this process, and the lessons learned from this experience.
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Affiliation(s)
- Judith Kallenberg
- Judith Kallenberg is head of policy at Gavi, the Vaccine Alliance, in Geneva, Switzerland
| | - Wilson Mok
- Wilson Mok is senior manager of price forecasting at Gavi
| | - Robert Newman
- Robert Newman is Cambodia country director for the Centers for Disease Control and Prevention, in Phnom Penh. At the time this work was conducted, he was managing director of policy and performance at Gavi
| | - Aurélia Nguyen
- Aurélia Nguyen is director of policy and market shaping at Gavi
| | - Theresa Ryckman
- Theresa Ryckman is a program officer at the Results for Development Institute, in Washington, D.C
| | - Helen Saxenian
- Helen Saxenian is a health economist and independent consultant in Bethesda, Maryland
| | - Paul Wilson
- Paul Wilson is an assistant professor at the Mailman School of Public Health, Columbia University, in New York City
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Resch S, Ryckman T, Hecht R. Funding AIDS programmes in the era of shared responsibility: an analysis of domestic spending in 12 low-income and middle-income countries. Lancet Glob Health 2015; 3:e52-61. [PMID: 25539970 DOI: 10.1016/s2214-109x(14)70342-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND As the incomes of many AIDS-burdened countries grow and donors' budgets for helping to fight the disease tighten, national governments and external funding partners increasingly face the following question: what is the capacity of countries that are highly affected by AIDS to finance their responses from domestic sources, and how might this affect the level of donor support? In this study, we attempt to answer this question. METHODS We propose metrics to estimate domestic AIDS financing, using methods related to national prioritisation of health spending, disease burden, and economic growth. We apply these metrics to 12 countries in sub-Saharan Africa with a high prevalence of HIV/AIDS, generating scenarios of possible future domestic expenditure. We compare the results with total AIDS financing requirements to calculate the size of the resulting funding gaps and implications for donors. FINDINGS Nearly all 12 countries studied fall short of the proposed expenditure benchmarks. If they met these benchmarks fully, domestic spending on AIDS would increase by 2·5 times, from US$2·1 billion to $5·1 billion annually, covering 64% of estimated future funding requirements and leaving a gap of around a third of the total $7·9 billion needed. Although upper-middle-income countries, such as Botswana, Namibia, and South Africa, would become financially self-reliant, lower-income countries, such as Mozambique and Ethiopia, would remain heavily dependent on donor funds. INTERPRETATION The proposed metrics could be useful to stimulate further analysis and discussion around domestic spending on AIDS and corresponding donor contributions, and to structure financial agreements between recipient country governments and donors. Coupled with improved resource tracking, such metrics could enhance transparency and accountability for efficient use of money and maximise the effect of available funding to prevent HIV infections and save lives. FUNDING US Centers for Disease Control and Prevention.
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Affiliation(s)
| | | | - Robert Hecht
- Results for Development Institute, Washington, DC, USA.
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Piot P, Abdool Karim SS, Hecht R, Legido-Quigley H, Buse K, Stover J, Resch S, Ryckman T, Møgedal S, Dybul M, Goosby E, Watts C, Kilonzo N, McManus J, Sidibé M. Defeating AIDS--advancing global health. Lancet 2015; 386:171-218. [PMID: 26117719 DOI: 10.1016/s0140-6736(15)60658-4] [Citation(s) in RCA: 187] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Peter Piot
- London School of Hygiene & Tropical Medicine, London, UK.
| | | | - Robert Hecht
- Results for Development Institute, Washington, DC, USA
| | - Helena Legido-Quigley
- London School of Hygiene & Tropical Medicine, London, UK; Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | | | - Stephen Resch
- Harvard T H Chan School of Public Health, Center for Health Decision Science, Boston, MA, USA
| | | | - Sigrun Møgedal
- Norwegian Knowledge Centre for the Health Services, Oslo, Norway
| | - Mark Dybul
- Global Fund to Fight Aids, Tuberculosis and Malaria, Geneva, Switzerland
| | - Eric Goosby
- Global Health Sciences, University of California, San Francisco, CA, USA
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20
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Saxenian H, Hecht R, Kaddar M, Schmitt S, Ryckman T, Cornejo S. Overcoming challenges to sustainable immunization financing: early experiences from GAVI graduating countries. Health Policy Plan 2014; 30:197-205. [PMID: 24510369 PMCID: PMC4325534 DOI: 10.1093/heapol/czu003] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Over the 5-year period ending in 2018, 16 countries with a combined birth cohort of over 6 million infants requiring life-saving immunizations are scheduled to transition (graduate) from outside financial and technical support for a number of their essential vaccines. This support has been provided over the past decade by the GAVI Alliance. Will these 16 countries be able to continue to sustain these vaccination efforts? To address this issue, GAVI and its partners are supporting transition planning, entailing country assessments of readiness to graduate and intensive dialogue with national officials to ensure a smooth transition process. This approach was piloted in Bhutan, Republic of Congo, Georgia, Moldova and Mongolia in 2012. The pilot showed that graduating countries are highly heterogeneous in their capacity to assume responsibility for their immunization programmes. Although all possess certain strengths, each country displayed weaknesses in some of the following areas: budgeting for vaccine purchase, national procurement practices, performance of national regulatory agencies, and technical capacity for vaccine planning and advocacy. The 2012 pilot experience further demonstrated the value of transition planning processes and tools. As a result, GAVI has decided to continue with transition planning in 2013 and beyond. As the graduation process advances, GAVI and graduating countries should continue to contribute to global collective thinking about how developing countries can successfully end their dependence on donor aid and achieve self-sufficiency.
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Affiliation(s)
- Helen Saxenian
- Consultant to Results for Development Institute, Washington, DC 20005, USA, Results for Development Institute, Washington, DC 20005, USA, World Health Organization, 1211 Geneva, Switzerland, Consultant to World Health Organization, 1211 Geneva, Switzerland, GAVI Alliance, 1202 Geneva, Switzerland
| | - Robert Hecht
- Consultant to Results for Development Institute, Washington, DC 20005, USA, Results for Development Institute, Washington, DC 20005, USA, World Health Organization, 1211 Geneva, Switzerland, Consultant to World Health Organization, 1211 Geneva, Switzerland, GAVI Alliance, 1202 Geneva, Switzerland
| | - Miloud Kaddar
- Consultant to Results for Development Institute, Washington, DC 20005, USA, Results for Development Institute, Washington, DC 20005, USA, World Health Organization, 1211 Geneva, Switzerland, Consultant to World Health Organization, 1211 Geneva, Switzerland, GAVI Alliance, 1202 Geneva, Switzerland
| | - Sarah Schmitt
- Consultant to Results for Development Institute, Washington, DC 20005, USA, Results for Development Institute, Washington, DC 20005, USA, World Health Organization, 1211 Geneva, Switzerland, Consultant to World Health Organization, 1211 Geneva, Switzerland, GAVI Alliance, 1202 Geneva, Switzerland
| | - Theresa Ryckman
- Consultant to Results for Development Institute, Washington, DC 20005, USA, Results for Development Institute, Washington, DC 20005, USA, World Health Organization, 1211 Geneva, Switzerland, Consultant to World Health Organization, 1211 Geneva, Switzerland, GAVI Alliance, 1202 Geneva, Switzerland
| | - Santiago Cornejo
- Consultant to Results for Development Institute, Washington, DC 20005, USA, Results for Development Institute, Washington, DC 20005, USA, World Health Organization, 1211 Geneva, Switzerland, Consultant to World Health Organization, 1211 Geneva, Switzerland, GAVI Alliance, 1202 Geneva, Switzerland
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