Publications by authors named "Martin I Meltzer"

123 Publications

The urgency of resuming disrupted dog rabies vaccination campaigns: a modeling and cost-effectiveness analysis.

Sci Rep 2021 Jun 14;11(1):12476. Epub 2021 Jun 14.

Poxvirus and Rabies Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging & Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA.

Dog vaccination is a cost-effective approach to preventing human rabies deaths. In Haiti, the last nation-wide dog vaccination campaign occurred in 2018. We estimated the number of human lives that could be saved by resuming dog vaccination in 2021 compared to 2022 and compared the cost-effectiveness of these two scenarios. We modified a previously published rabies transmission and economic model to estimate trends in dog and human rabies cases in Haiti from 2005 to 2025, with varying assumptions about when dog vaccinations resume. We compared model outputs to surveillance data on human rabies deaths from 2005 to 2020 and animal rabies cases from 2018 to 2020. Model predictions and surveillance data both suggest a 5- to 8-fold increase in animal rabies cases occurred in Haiti's capital city between Fall 2019 and Fall 2020. Restarting dog vaccination in Haiti in 2021 compared to 2022 could save 285 human lives and prevent 6541 human rabies exposures over a five-year period. It may also decrease program costs due to reduced need for human post-exposure prophylaxis. These results show that interruptions in dog vaccination campaigns before elimination is achieved can lead to significant human rabies epidemics if not promptly resumed.
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http://dx.doi.org/10.1038/s41598-021-92067-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8203735PMC
June 2021

Cost effectiveness and impact of a targeted age- and incidence-based West Nile virus vaccine strategy.

Clin Infect Dis 2021 Jun 12. Epub 2021 Jun 12.

Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), Fort Collins, Colorado, USA.

Background: West Nile virus (WNV) is the leading cause of arboviral disease in the United States and is associated with significant morbidity and mortality. A previous analysis found that a vaccination program targeting persons aged ≥60 years was more cost effective than universal vaccination, but costs remained high.

Methods: We used a mathematical Markov model to evaluate cost-effectiveness of an age- and incidence-based WNV vaccination program. We grouped states and large counties (≥100,000 persons aged ≥60 years) by median annual WNV incidence rates from 2004 to 2017 for persons aged ≥60 years. We defined WNV incidence thresholds, in increments of 0.5 cases per 100,000 persons ≥60 years. We calculated potential cost per WNV vaccine-prevented case and per quality adjusted life years (QALYs) saved.

Results: Vaccinating persons aged ≥60 years in states with an annual incidence of WNV neuroinvasive disease of ≥0.5 per 100,000 resulted in approximately half the cost per health outcome averted compared to vaccinating persons aged ≥60 years in all the contiguous United States. This approach could potentially prevent 37% of all neuroinvasive disease cases and 63% of WNV-related deaths nationally. Employing such a threshold at a county-level further improved cost-effectiveness ratios while preventing 19% and 30% of WNV-related neuroinvasive disease cases and deaths, respectively.

Conclusions: An age- and incidence-based WNV vaccination program could be a more cost-effective strategy than an age-based program while still having a substantial impact on lowering WNV-related morbidity and mortality.
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http://dx.doi.org/10.1093/cid/ciab540DOI Listing
June 2021

Modeling the Transmission of Covid-19: Impact of Mitigation Strategies in Prekindergarten-Grade 12 Public Schools, United States, 2021.

J Public Health Manag Pract 2021 Apr 30. Epub 2021 Apr 30.

Division of Injury Prevention, National Center for Injury Prevention and Control (Drs Miller and Rice), Division of Preparedness and Emerging Infections, National Center for Emerging & Zoonotic Infectious Diseases (Drs Greening Jr and Meltzer), Policy Research, Analysis, and Development Office, Office of the Associate Director for Policy and Strategy (Dr Arifkhanova), and Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention & Health Promotion (Dr Coronado), Centers for Disease Control and Prevention, Atlanta, Georgia.

Background: Schools are an integral part of the community; however, congregate settings facilitate transmission of SARS-CoV-2, presenting a challenge to school administrators to provide a safe, in-school environment for students and staff.

Methods: We adapted the Centers for Disease Control and Prevention's COVIDTracer Advanced tool to model the transmission of SARS-CoV-2 in a school of 596 individuals. We estimate possible reductions in cases and hospitalizations among this population using a scenario-based analysis that accounts for (a) the risk of importation of infection from the community; (b) adherence to key Centers for Disease Control and Prevention-recommended mitigation strategies: mask wearing, cleaning and disinfection, hand hygiene, and social distancing; and (c) the effectiveness of contact tracing interventions at limiting onward transmission.

Results: Low impact and effectiveness of mitigation strategies (net effectiveness: 27%) result in approximately 40% of exposed staff and students becoming COVID-19 cases. When the net effectiveness of mitigation strategies was 69% or greater, in-school transmission was mostly prevented, yet importation of cases from the surrounding community could result in nearly 20% of the school's population becoming infected within 180 days. The combined effects of mitigation strategies and contact tracing were able to prevent most onward transmission. Hospitalizations were low among children and adults (<0.5% of the school population) across all scenarios examined.

Conclusions: Based on our model, layering mitigation strategies and contact tracing can limit the number of cases that may occur from transmission in schools. Schools in communities with substantial levels of community spread will need to be more vigilant to ensure adherence of mitigation strategies to minimize transmission. Our results show that for school administrators, teachers, and parents to provide the safest environment, it is important to utilize multiple mitigation strategies and contract tracing that reduce SARS CoV-2 transmission by at least 69%. This will require training, reinforcement, and vigilance to ensure that the highest level of adherence is maintained over the entire school term.
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http://dx.doi.org/10.1097/PHH.0000000000001373DOI Listing
April 2021

Cost-effectiveness of the national dog rabies prevention and control program in Mexico, 1990-2015.

PLoS Negl Trop Dis 2021 03 4;15(3):e0009130. Epub 2021 Mar 4.

Coordinador Estatal de Zoonosis, Secretaría de Salud Tlaxcala, México.

Background: Rabies is a viral zoonosis that imposes a substantial disease and economic burden in many developing countries. Dogs are the primary source of rabies transmission; eliminating dog rabies reduces the risk of exposure in humans significantly. Through mass annual dog rabies vaccination campaigns, the national program of rabies control in Mexico progressively reduced rabies cases in dogs and humans since 1990. In 2019, the World Health Organization validated Mexico for eliminating rabies as a public health problem. Using a governmental perspective, we retrospectively assessed the economic costs, effectiveness, and cost-effectiveness of the national program of rabies control in Mexico, 1990-2015.

Methodology: Combining various data sources, including administrative records, national statistics, and scientific literature, we retrospectively compared the current scenario of annual dog vaccination campaigns and post-exposure prophylaxis (PEP) with a counterfactual scenario without an annual dog vaccination campaign but including PEP. The counterfactual scenario was estimated using a mathematical model of dog rabies transmission (RabiesEcon). We performed a thorough sensitivity analysis of the main results.

Principal Findings: Results suggest that in 1990 through 2015, the national dog rabies vaccination program in Mexico prevented about 13,000 human rabies deaths, at an incremental cost (MXN 2015) of $4,700 million (USD 300 million). We estimated an average cost of $360,000 (USD 23,000) per human rabies death averted, $6,500 (USD 410) per additional year-of-life, and $3,000 (USD 190) per dog rabies death averted. Results were robust to several counterfactual scenarios, including high and low rabies transmission scenarios and various assumptions about potential costs without mass dog rabies vaccination campaigns.

Conclusions: Annual dog rabies vaccination campaigns have eliminated the transmission of dog-to-dog rabies and dog-mediated human rabies deaths in Mexico. According to World Health Organization standards, our results show that the national program of rabies control in Mexico has been highly cost-effective.
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http://dx.doi.org/10.1371/journal.pntd.0009130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7963054PMC
March 2021

Estimated Resource Costs for Implementation of CDC's Recommended COVID-19 Mitigation Strategies in Pre-Kindergarten through Grade 12 Public Schools - United States, 2020-21 School Year.

MMWR Morb Mortal Wkly Rep 2020 Dec 18;69(50):1917-1921. Epub 2020 Dec 18.

CDC COVID-19 Response Team.

As school districts across the United States consider how to safely operate during the 2020-21 academic year, CDC recommends mitigation strategies that schools can adopt to reduce the risk for transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1). To identify the resources and costs needed to implement school-based mitigation strategies and provide schools and jurisdictions with information to aid resource allocation, a microcosting methodology was employed to estimate costs in three categories: materials and consumables, additional custodial staff members, and potential additional transportation. National average estimates, using the national pre-kindergarten through grade 12 (preK-12) public enrollment of 50,685,567 students, range between a mean of $55 (materials and consumables only) to $442 (all three categories) per student. State-by-state estimates of additional funds needed as a percentage of fiscal year 2018 student expenditures (2) range from an additional 0.3% (materials and consumables only) to 7.1% (all three categories); however, only seven states had a maximum estimate above 4.2%. These estimates, although not exhaustive, highlight the level of resources needed to ensure that schools reopen and remain open in the safest possible manner and offer administrators at schools and school districts and other decision-makers the cost information necessary to budget and prioritize school resources during the COVID-19 pandemic.
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http://dx.doi.org/10.15585/mmwr.mm6950e1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7745954PMC
December 2020

Epidemiology and cost of Lyme disease-related hospitalizations among patients with employer-sponsored health insurance-United States, 2005-2014.

Zoonoses Public Health 2020 06;67(4):407-415

Division of Vector-Borne Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Fort Collins, CO, USA.

An estimated 300,000 cases of Lyme disease occur in the United States annually. Disseminated Lyme disease may result in carditis, arthritis, facial palsy or meningitis, sometimes requiring hospitalization. We describe the epidemiology and cost of Lyme disease-related hospitalizations. We analysed 2005-2014 data from the Truven Health Analytics MarketScan Commercial Claims and Encounters Databases to identify inpatient records associated with Lyme disease based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. We estimated the annual number and median cost of Lyme disease-related hospitalizations in the United States in persons under 65 years of age. Costs were adjusted to reflect 2016 dollars. Of 20,983,165 admission records contained in the inpatient databases during the study period, 2,823 (0.01%) met inclusion criteria for Lyme disease-related hospitalizations. Over half of the identified records contained an ICD-9-CM code for meningitis (n = 614), carditis (n = 429), facial palsy (n = 400) or arthritis (n = 377). Nearly 60% of hospitalized patients were male. The median cost per Lyme disease-related hospitalization was $11,688 (range: $140-$323,613). The manifestation with the highest median cost per stay was carditis ($17,461), followed by meningitis ($15,177), arthritis ($13,012) and facial palsy ($10,491). Median cost was highest among the 15- to 19-year-old age group ($12,991). Admissions occurring in January had the highest median cost ($13,777) for all study years. Based on extrapolation to the U.S. population, we estimate that 2,196 Lyme disease-related hospitalizations in persons under 65 years of age occur annually with an estimated annual cost of $25,826,237. Lyme disease is usually treated in an outpatient setting; however, some patients with Lyme disease require hospitalization, underscoring the need for effective prevention methods to mitigate these serious cases. Information from this analysis can aid economic evaluations of interventions that prevent infection and advances in disease detection.
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http://dx.doi.org/10.1111/zph.12699DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7521202PMC
June 2020

Using Twitter to Track Unplanned School Closures: Georgia Public Schools, 2015-17.

Disaster Med Public Health Prep 2020 May 14:1-5. Epub 2020 May 14.

Department of Biostatistics, Epidemiology and Environmental Health Sciences, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia.

Objectives: To aid emergency response, Centers for Disease Control and Prevention (CDC) researchers monitor unplanned school closures (USCs) by conducting online systematic searches (OSS) to identify relevant publicly available reports. We examined the added utility of analyzing Twitter data to improve USC monitoring.

Methods: Georgia public school data were obtained from the National Center for Education Statistics. We identified school and district Twitter accounts with 1 or more tweets ever posted ("active"), and their USC-related tweets in the 2015-16 and 2016-17 school years. CDC researchers provided OSS-identified USC reports. Descriptive statistics, univariate, and multivariable logistic regression were computed.

Results: A majority (1,864/2,299) of Georgia public schools had, or were in a district with, active Twitter accounts in 2017. Among these schools, 638 were identified with USCs in 2015-16 (Twitter only, 222; OSS only, 2015; both, 201) and 981 in 2016-17 (Twitter only, 178; OSS only, 107; both, 696). The marginal benefit of adding Twitter as a data source was an increase in the number of schools identified with USCs by 53% (222/416) in 2015-16 and 22% (178/803) in 2016-17.

Conclusions: Policy-makers may wish to consider the potential value of incorporating Twitter into existing USC monitoring systems.
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http://dx.doi.org/10.1017/dmp.2020.65DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7665976PMC
May 2020

Comparative economic analysis of strategies for Japanese encephalitis vaccination of U.S. travelers.

Vaccine 2020 04 10;38(17):3351-3357. Epub 2020 Mar 10.

Division of Preparedness and Emerging Infections, Emergency Preparedness and Response Branch, Centers for Disease Control and Prevention, 1600 Clifton Road MS H24-11, Atlanta, GA 30329, United States.

Background: Japanese encephalitis (JE) virus is the leading vaccine-preventable cause of encephalitis in Asia. For most travelers, JE risk is very low but varies based on several factors, including travel duration, location, and activities. To aid public health officials, health care providers, and travelers evaluate the worth of administering/ receiving pre-travel JE vaccinations, we estimated the numbers-needed-to-treat to prevent a case and the cost-effectiveness ratios of JE vaccination for U.S. travelers in different risk categories.

Methods: We used a decision tree model to estimate cost per case averted from a societal and traveler perspective for hypothetical cohorts of vaccinated and unvaccinated travelers. Risk Category I included travelers planning to spend ≥1 month in JE-endemic areas, Risk Category II were shorter-term (<1 month) travelers spending ≥20% of their time doing outdoor activities in rural areas, and Risk Category III were all remaining travelers. We performed sensitivity analyses including examining changes in cost-effectiveness with 10- and 100-fold increases in incidence and medical treatment costs.

Results: The numbers-needed-to-treat to prevent a case and cost per case averted were approximately 0.7 million and $0.6 billion for Risk Category I, 1.6 million and $1.2 billion for Risk Category II, and 9.8 million and $7.6 billion for Risk Category III. Increases of 10-fold and 100-fold in disease incidence proportionately decreased cost-effectiveness ratios. Similar levels of increases in medical treatment costs resulted in negligible changes in cost-effectiveness ratios.

Conclusion: Numbers-needed-to-treat and cost-effectiveness ratios associated with preventing JE cases in U.S. travelers by vaccination varied greatly by risk category and disease incidence. While cost effectiveness ratios are not the sole rationale for decision-making regarding JE vaccination, the results presented here can aid in making such decisions under very different risk and cost scenarios.
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http://dx.doi.org/10.1016/j.vaccine.2020.02.032DOI Listing
April 2020

Uncrewed aircraft systems versus motorcycles to deliver laboratory samples in west Africa: a comparative economic study.

Lancet Glob Health 2020 01;8(1):e143-e151

Office of the Director, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.

Background: Transportation of laboratory samples in low-income and middle-income countries is often constrained by poor road conditions, difficult geographical terrain, and insecurity. These constraints can lead to long turnaround times for laboratory diagnostic tests and hamper epidemic control or patient treatment efforts. Although uncrewed aircraft systems (UAS)-ie, drones-can mitigate some of these transportation constraints, their cost-effectiveness compared with land-based transportation systems is unclear.

Methods: We did a comparative economic study of the costs and cost-effectiveness of UAS versus motorcycles in Liberia (west Africa) for transportation of laboratory samples under simulated routine conditions and public health emergency conditions (based on the 2013-16 west African Ebola virus disease epidemic). We modelled three UAS with operational ranges of 30 km, 65 km, and 100 km (UAS30, UAS65, and UAS100) and lifespans of 1000 to 10 000 h, and compared the costs and number of samples transported with an established motorcycle transportation programme (most commonly used by the Liberian Ministry of Health and the charity Riders for Health). Data for UAS were obtained from Skyfire (a UAS consultancy), Vayu (a UAS manufacturer), and Sandia National Laboratories (a private company with UAS research experience). Motorcycle operational data were obtained from Riders for Health. In our model, we included costs for personnel, equipment, maintenance, and training, and did univariate and probabilistic sensitivity analyses for UAS lifespans, range, and accident or failures.

Findings: Under the routine scenario, the per sample transport costs were US$0·65 (95% CI 0·01-2·85) and $0·82 (0·56-5·05) for motorcycles and UAS65, respectively. Per-sample transport costs under the emergency scenario were $24·06 (95% CI 21·14-28·20) for motorcycles, $27·42 (95% CI 19·25-136·75) for an unadjusted UAS model with insufficient geographical coverage, and $34·09 (95% CI 26·70-127·40) for an adjusted UAS model with complementary motorcycles. Motorcycles were more cost-effective than short-range UAS (ie, UAS30). However, with increasing range and operational lifespans, UAS became increasingly more cost-effective.

Interpretation: Given the current level of technology, purchase prices, equipment lifespans, and operational flying ranges, UAS are not a viable option for routine transport of laboratory samples in west Africa. Field studies are required to generate evidence about UAS lifespan, failure rates, and performance under different weather conditions and payloads.

Funding: None.
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http://dx.doi.org/10.1016/S2214-109X(19)30464-4DOI Listing
January 2020

Determining the post-elimination level of vaccination needed to prevent re-establishment of dog rabies.

PLoS Negl Trop Dis 2019 12 2;13(12):e0007869. Epub 2019 Dec 2.

Poxvirus and Rabies Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging & Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.

Background: Once a canine rabies-free status has been achieved, there is little guidance available on vaccination standards to maintain that status. In areas with risk of reintroduction, it may be practical to continue vaccinating portions of susceptible dogs to prevent re-establishment of canine rabies.

Methods: We used a modified version of RabiesEcon, a deterministic mathematical model, to evaluate the potential impacts and cost-effectiveness of preventing the reintroduction of canine rabies through proactive dog vaccination. We analyzed four scenarios to simulate varying risk levels involving the reintroduction of canine rabies into an area where it is no longer present. In a sensitivity analysis, we examined the influences of reintroduction frequency and intensity, the density of susceptible dog population, dog birth rate, dog life expectancy, vaccine efficacy, rate of loss of vaccine immunity, and the basic reproduction number (R0).

Results: To prevent the re-establishment of canine rabies, it is necessary to vaccinate 38% to 56% of free-roaming dogs that have no immunity to rabies. These coverage levels were most sensitive to adjustments in R0 followed by the vaccine efficacy and the rate of loss of vaccine immunity. Among the various preventive vaccination strategies, it was most cost-effective to continue dog vaccination at the minimum coverage required, with the average cost per human death averted ranging from $257 to $398 USD.

Conclusions: Without strong surveillance systems, rabies-free countries are vulnerable to becoming endemic when incursions happen. To prevent this, it may be necessary to vaccinate at least 38% to 56% of the susceptible dog population depending on the risk of reintroduction and transmission dynamics.
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http://dx.doi.org/10.1371/journal.pntd.0007869DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6907870PMC
December 2019

Forecasting the 2014 West African Ebola Outbreak.

Epidemiol Rev 2019 01;41(1):34-50

In 2014-2015, a large Ebola outbreak afflicted Liberia, Guinea, and Sierra Leone. We performed a systematic review of 26 manuscripts, published between 2014 and April 2015, that forecasted the West African Ebola outbreak while it was occurring, and we derived implications for how results could be interpreted by policymakers. Forecasted case counts varied widely. An important determinant of forecast accuracy for case counts was how far into the future predictions were made. Generally, forecasts for less than 2 months into the future tended to be more accurate than those made for more than 10 weeks into the future. The exceptions were parsimonious statistical models in which the decay of the rate of spread of the pathogen among susceptible individuals was dealt with explicitly. The most important lessons for policymakers regarding future outbreaks, when using similar modeling results, are: 1) uncertainty of forecasts will be greater in the beginning of the outbreak; 2) when data are limited, forecasts produced by models designed to inform specific decisions should be used complementarily for robust decision-making (e.g., 2 statistical models produced the most reliable case-counts forecasts for the studied Ebola outbreak but did not enable understanding of interventions' impact, whereas several compartmental models could estimate interventions' impact but required unavailable data); and 3) timely collection of essential data is necessary for optimal model use.
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http://dx.doi.org/10.1093/epirev/mxz013DOI Listing
January 2019

Estimating the impact of multiple immunization products on medically-attended respiratory syncytial virus (RSV) infections in infants.

Vaccine 2020 01 16;38(2):251-257. Epub 2019 Nov 16.

US Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA; National Center for Immunization and Respiratory Diseases (NCIRD), USA.

Background: Palivizumab, a monoclonal antibody and the only licensed immunization product for preventing respiratory syncytial virus (RSV) infection, is recommended for children with certain high-risk conditions. Other antibody products and maternal vaccines targeting young infants are in clinical development. Few studies have compared products closest to potential licensure and have primarily focused on the effects on hospitalizations only. Estimates of the impact of these products on medically-attended (MA) infections in a variety of healthcare settings are needed to assist with developing RSV immunization recommendations.

Methods: We developed a tool for practicing public health officials to estimate the impact of immunization strategies on RSV-associated MA lower respiratory tract infections (LRTIs) in various healthcare settings among infants <12 months. Users input RSV burden and seasonality and examine the influence of altering product efficacy and uptake assumptions. We used the tool to evaluate candidate products' impacts among a US birth cohort.

Results: We estimated without immunization, 407,360 (range: 339,650-475,980) LRTIs are attended annually in outpatient clinics, 147,240 (126,070-168,510) in emergency departments (EDs), and 33,180 (24,760-42,900) in hospitals. A passive antibody candidate targeting all infants prevented the most LRTIs: 196,470 (48% of visits without immunization) outpatient clinic visits (range: 163,810-229,650), 75,250 (51%) EDs visits (64,430-86,090), and 18,140 (55%) hospitalizations (13,770-23,160). A strategy combining maternal vaccine candidate and palivizumab prevented 58,210 (14% of visits without immunization) LRTIs in outpatient clinics (range: 48,520-67,970), 19,580 (13%) in EDs (16,760-22,400), and 8,190 (25%) hospitalizations (6,390-10,150).

Conclusions: Results underscore the potential for anticipated products to reduce serious RSV illness. Our tool (provided to readers) can be used by different jurisdictions and accept updated data. Results can aid economic evaluations and public health decision-making regarding RSV immunization products.
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http://dx.doi.org/10.1016/j.vaccine.2019.10.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7029767PMC
January 2020

The PanVax Tool to Improve Pandemic Influenza Emergency Vaccination Program Readiness and Partnership.

Am J Public Health 2019 09;109(S4):S322-S324

Cristina Carias, Bradford Greening Jr, Emily B. Kahn, and Martin I. Meltzer are with the Health Economics and Modeling Unit, Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA. Jonathan D. Lehnert, Bishwa B. Adhikari, and Samuel B. Graitcer are with the Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention. Jonathan D. Lehnert is also with IHRC, Atlanta.

To show how the Centers for Disease Control and Prevention's Pandemic Vaccine Campaign Planning Tool (PanVax Tool) can help state and local public health emergency planners demonstrate and quantify how partnerships with community vaccine providers can improve their overall pandemic vaccination program readiness. The PanVax Tool helps planners compare different strategies to vaccinate their jurisdiction's population in a severe pandemic by allowing users to customize the underlying model inputs in real time, including their jurisdiction's size, community vaccine provider types, and how they allocate vaccine to these providers. In this report, we used a case study with hypothetical data to illustrate how jurisdictions can utilize the PanVax Tool for preparedness planning. By using the tool, planners are able to understand the impact of engaging with different vaccine providers in a vaccination campaign. The PanVax Tool is a useful tool to help demonstrate the impact of community vaccine provider partnerships on pandemic vaccination readiness and identify areas for improved partnerships for pandemic response.
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http://dx.doi.org/10.2105/AJPH.2019.305233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6737806PMC
September 2019

Cost-effectiveness of increased influenza vaccination uptake against readmissions of major adverse cardiac events in the US.

PLoS One 2019 29;14(4):e0213499. Epub 2019 Apr 29.

Immunization Services Division, National Center for Immunization and Respiratory Diseases, (CDC), Atlanta, GA, United States of America.

Background: Although influenza vaccination has been shown to reduce the incidence of major adverse cardiac events (MACE) among those with existing cardiovascular disease (CVD), in the 2015-16 season, coverage for persons with heart disease was only 48% in the US.

Methods: We built a Monte Carlo (probabilistic) spreadsheet-based decision tree in 2018 to estimate the cost-effectiveness of increased influenza vaccination to prevent MACE readmissions. We based our model on current US influenza vaccination coverage of the estimated 493,750 US acute coronary syndrome (ACS) patients from the healthcare payer perspective. We excluded outpatient costs and time lost from work and included only hospitalization and vaccination costs. We also estimated the incremental cost/MACE case averted and incremental cost/QALY gained (ICER) if 75% hospitalized ACS patients were vaccinated by discharge and estimated the impact of increasing vaccination coverage incrementally by 5% up to 95% in a sensitivity analysis, among hospitalized adults aged ≥ 65 years and 18-64 years, and varying vaccine effectiveness from 30-40%.

Result: At 75% vaccination coverage by discharge, vaccination was cost-saving from the healthcare payer perspective in adults ≥ 65 years and the ICER was $12,680/QALY (95% CI: 6,273-20,264) in adults 18-64 years and $2,400 (95% CI: -1,992-7,398) in all adults 18 + years. These resulted in ~ 500 (95% CI: 439-625) additional averted MACEs/year for all adult patients aged ≥18 years and added ~700 (95% CI: 578-825) QALYs. In the sensitivity analysis, vaccination becomes cost-saving in adults 18+years after about 80% vaccination rate. To achieve 75% vaccination rate in all adults aged ≥ 18 years will require an additional cost of $3 million. The effectiveness of the vaccine, cost of vaccination, and vaccination coverage rate had the most impact on the results.

Conclusion: Increasing vaccination rate among hospitalized ACS patients has a favorable cost-effectiveness profile and becomes cost-saving when at least 80% are vaccinated.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0213499PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6488048PMC
December 2019

How did Ebola information spread on twitter: broadcasting or viral spreading?

BMC Public Health 2019 Apr 25;19(1):438. Epub 2019 Apr 25.

Journalism and Media Studies Centre, The University of Hong Kong, Hong Kong, Hong Kong.

Background: Information and emotions towards public health issues could spread widely through online social networks. Although aggregate metrics on the volume of information diffusion are available, we know little about how information spreads on online social networks. Health information could be transmitted from one to many (i.e. broadcasting) or from a chain of individual to individual (i.e. viral spreading). The aim of this study is to examine the spreading pattern of Ebola information on Twitter and identify influential users regarding Ebola messages.

Methods: Our data was purchased from GNIP. We obtained all Ebola-related tweets posted globally from March 23, 2014 to May 31, 2015. We reconstructed Ebola-related retweeting paths based on Twitter content and the follower-followee relationships. Social network analysis was performed to investigate retweeting patterns. In addition to describing the diffusion structures, we classify users in the network into four categories (i.e., influential user, hidden influential user, disseminator, common user) based on following and retweeting patterns.

Results: On average, 91% of the retweets were directly retweeted from the initial message. Moreover, 47.5% of the retweeting paths of the original tweets had a depth of 1 (i.e., from the seed user to its immediate followers). These observations suggested that the broadcasting was more pervasive than viral spreading. We found that influential users and hidden influential users triggered more retweets than disseminators and common users. Disseminators and common users relied more on the viral model for spreading information beyond their immediate followers via influential and hidden influential users.

Conclusions: Broadcasting was the dominant mechanism of information diffusion of a major health event on Twitter. It suggests that public health communicators can work beneficially with influential and hidden influential users to get the message across, because influential and hidden influential users can reach more people that are not following the public health Twitter accounts. Although both influential users and hidden influential users can trigger many retweets, recognizing and using the hidden influential users as the source of information could potentially be a cost-effective communication strategy for public health promotion. However, challenges remain due to uncertain credibility of these hidden influential users.
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http://dx.doi.org/10.1186/s12889-019-6747-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6485141PMC
April 2019

Evaluation of the impact of shigellosis exclusion policies in childcare settings upon detection of a shigellosis outbreak.

BMC Infect Dis 2019 Feb 19;19(1):172. Epub 2019 Feb 19.

National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, H24-11, Atlanta, GA, 30329-4027, USA.

Background: In the event of a shigellosis outbreak in a childcare setting, exclusion policies are typically applied to afflicted children to limit shigellosis transmission. However, there is scarce evidence of their impact.

Methods: We evaluated five exclusion policies: Children return to childcare after: i) two consecutive laboratory tests (either PCR or culture) do not detect Shigella, ii) a single negative laboratory test (PCR or culture) does not detect Shigella, iii) seven days after beginning antimicrobial treatment, iv) after being symptom-free for 24 h, or v) 14 days after symptom onset. We also included four treatments to assess the policy options: i) immediate, effective treatment; ii) effective treatment after laboratory diagnosis; iii) no treatment; iv) ineffective treatment. Relying on published data, we calculated the likelihood that a child reentering childcare would be infectious, and the number of childcare-days lost per policy.

Results: Requiring two consecutive negative PCR tests yielded a probability of onward transmission of < 1%, with up to 17 childcare-days lost for children receiving effective treatment, and 53 days lost for those receiving ineffective treatment.

Conclusions: Of the policies analyzed, requiring negative PCR testing before returning to childcare was the most effective to reduce the risk of shigellosis transmission, with one PCR test being the most effective for the least childcare-days lost.
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http://dx.doi.org/10.1186/s12879-019-3796-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6379933PMC
February 2019

Assessment of age-related differences in smoking status and health-related quality of life (HRQoL): Findings from the 2016 Behavioral Risk Factor Surveillance System.

J Community Psychol 2019 01 10;47(1):93-103. Epub 2018 Jul 10.

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, US Centers for Disease Control and Prevention.

Despite significant declines in the use of cigarettes, a significant proportion of adults smoke. This study explores the association between smoking and health-related quality of life (HRQoL) by age. The 2016 Behavioral Risk Factor Surveillance System survey was administered to adults in 50 states and District of Columbia (n = 437,195). Physically unhealthy days (PUDs) and mentally unhealthy days (MUDs)) were regressed on age strata (18-24, 25-34, 35-44, 45-54, 55-64, ≥ 65 years) and smoking status (never, former, someday, and everyday) using negative binomial regression models with adjustment for sociodemographic covariates. For each age group, everyday smoking highly predicted PUDs and MUDs. Predicted PUDs increased with age; predicted MUDs decreased with age. Among adults aged 45-54 and 55-64 years, 3-day difference in PUDs was observed between never smokers and everyday smokers. Among young adults (18-24 years), a 4.3-day difference in MUDs was observed between everyday and never smokers. The discrepancies were nonlinear with age. The observed relationship between smoking and HRQoL provides novel information about the need to consider age when designing community-based interventions. Additional research can provide needed depth to understanding the relationship between smoking and HRQoL in specific age groups.
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http://dx.doi.org/10.1002/jcop.22101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568861PMC
January 2019

Resources needed for US CDC's support to the response to post-epidemic clusters of Ebola in West Africa, 2016.

Infect Dis Poverty 2018 Oct 12;7(1):113. Epub 2018 Oct 12.

Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA.

Background: West African countries Liberia, Sierra Leone, and Guinea experienced the largest and longest epidemic of Ebola virus disease from 2014 to 2016; after the epidemic was declared to be over, Liberia, Guinea, and Sierra Leone still experienced Ebola cases/clusters. The United States Centers for Disease Control and Prevention (US CDC) participated in the response efforts to the latter Ebola clusters, by assisting with case investigation, contact identification, and monitoring. This study aims to estimate the cost to the US CDC of responding to three different Ebola clusters after the end of the Ebola epidemic in 2015: i) Sierra Leone, Tonkolili (Jan 2016, 2 Ebola cases, 5 affected regions); ii) Guinea, Nzerekore (Mar-May 2016, 10 Ebola cases, 2 affected regions); iii) Liberia, Somali Drive (Mar 2016, 3 Ebola cases, 1 affected region).

Main Text: After interviewing team members that had participated in the response, we estimated total costs (expressed in 2016 US Dollars [USD]), where total costs correspond to travel costs, deployed personnel costs, costs to prepare for deployment, procurement and interagency collaboration costs, among others. We also estimated cost per cluster case (corresponding to the total costs divided by the total number of cluster cases); and cost per case-affected-region (equal to the total costs divided by the product of the number of cases times the number of regions affected). We found that the response cost varied sixteenfold between USD 113 166 in Liberia and USD 1 764 271 in Guinea, where the main cost drivers were travel and personnel costs. The cost per cluster case varied tenfold between 37 722 in Liberia (three cases) and USD 347 226 in Sierra Leone, and the cost per case-affected-region varied threefold between USD 37 722 in Liberia and USD 88 214 in Guinea.

Conclusions: Costs vary with the characteristics of each cluster, with those spanning more regions and cases requiring more resources for case investigation and contact identification and monitoring. These data will assist policy makers plan for similar post-epidemic responses.
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http://dx.doi.org/10.1186/s40249-018-0484-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206714PMC
October 2018

Estimating Weekly Call Volume to a National Nurse Telephone Triage Line in an Influenza Pandemic.

Health Secur 2018 Sep/Oct;16(5):334-340

Bishwa B. Adhikari, PhD, is a Senior Economist; Michael L. Washington, PhD, is a Health Scientist; Emily B. Kahn, PhD, is a Senior Epidemiologist; and Martin I. Meltzer, PhD, is Senior Health Economist/Distinguished Consultant; all at the National Center for Emerging & Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC), Atlanta, GA. Lisa M. Koonin, DrPH, MN, MPH, is Deputy Director, Influenza Coordination Unit, National Center for Immunization & Respiratory Diseases, CDC, Atlanta. Melissa L. Mugambi, PhD, is Assistant Professor, Department of Global Health, University of Washington , Seattle, WA. Kellye D. Sliger, MPH, is an Epidemiologist, Oak Ridge Associated Universities, Oak Ridge, TN. The authors are solely responsible for the content of this article; the views presented do not necessarily represent the official views of the Centers for Disease Control and Prevention. The authors have no conflicts of interest.

Telephone nurse triage lines, such as the Centers for Disease Control and Prevention's (CDC) Flu on Call, a national nurse triage line, may help reduce the surge in demand for health care during an influenza pandemic by triaging callers, providing advice about clinical care and information about the pandemic, and providing access to prescription antiviral medication. We developed a Call Volume Projection Tool to estimate national call volume to Flu on Call during an influenza pandemic. The tool incorporates 2 influenza clinical attack rates (20% and 30%), 4 different levels of pandemic severity, and different initial "seed numbers" of cases (10 or 100), and it allows variation in which week the nurse triage line opens. The tool calculates call volume by using call-to-hospitalization ratios based on pandemic severity. We derived data on nurse triage line calls and call-to-hospitalization ratios from experience with the 2009 Minnesota FluLine nurse triage line. Assuming a 20% clinical attack rate and a case hospitalization rate of 0.8% to 1.5% (1968-like pandemic severity), we estimated the nationwide number of calls during the peak week of the pandemic to range from 1,551,882 to 3,523,902. Assuming a more severe 1957-like pandemic (case hospitalization rate = 1.5% to 3.0%), the national number of calls during the peak week of the pandemic ranged from 2,909,778 to 7,047,804. These results will aid in planning and developing nurse triage lines at both the national and state levels for use during a future influenza pandemic.
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http://dx.doi.org/10.1089/hs.2018.0061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6707072PMC
February 2019

Estimating dengue under-reporting in Puerto Rico using a multiplier model.

PLoS Negl Trop Dis 2018 08 6;12(8):e0006650. Epub 2018 Aug 6.

Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States of America.

Dengue is a mosquito-borne viral illness that causes a variety of health outcomes, from a mild acute febrile illness to potentially fatal severe dengue. Between 2005 and 2010, the annual number of suspected dengue cases reported to the Passive Dengue Surveillance System (PDSS) in Puerto Rico ranged from 2,346 in 2006 to 22,496 in 2010. Like other passive surveillance systems, PDSS is subject to under-reporting. To estimate the degree of under-reporting in Puerto Rico, we built separate inpatient and outpatient probability-based multiplier models, using data from two different surveillance systems-PDSS and the enhanced dengue surveillance system (EDSS). We adjusted reported cases to account for sensitivity of diagnostic tests, specimens with indeterminate results, and differences between PDSS and EDSS in numbers of reported dengue cases. In addition, for outpatients, we adjusted for the fact that less than 100% of medical providers submit diagnostic specimens from suspected cases. We estimated that a multiplication factor of between 5 (for 2010 data) to 9 (for 2006 data) must be used to correct for the under-reporting of the number of laboratory-positive dengue inpatients. Multiplication factors of between 21 (for 2010 data) to 115 (for 2008 data) must be used to correct for the under-reporting of laboratory-positive dengue outpatients. We also estimated that, after correcting for underreporting, the mean annual rate, for 2005-2010, of medically attended dengue in Puerto Rico to be between 2.1 (for dengue inpatients) to 7.8 (for dengue outpatients) per 1,000 population. These estimated rates compare to the reported rates of 0.4 (dengue outpatients) to 0.1 (dengue inpatients) per 1,000 population. The multipliers, while subject to limitations, will help public health officials correct for underreporting of dengue cases, and thus better evaluate the cost-and-benefits of possible interventions.
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http://dx.doi.org/10.1371/journal.pntd.0006650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6095627PMC
August 2018

Antiviral treatment for outpatient use during an influenza pandemic: a decision tree model of outcomes averted and cost-effectiveness.

J Public Health (Oxf) 2019 06;41(2):379-390

Centers for Disease Control and Prevention, Atlanta, GA, USA.

Background: Many countries have acquired antiviral stockpiles for pandemic influenza mitigation and a significant part of the stockpile may be focussed towards community-based treatment.

Methods: We developed a spreadsheet-based, decision tree model to assess outcomes averted and cost-effectiveness of antiviral treatment for outpatient use from the perspective of the healthcare payer in the UK. We defined five pandemic scenarios-one based on the 2009 A(H1N1) pandemic and four hypothetical scenarios varying in measures of transmissibility and severity.

Results: Community-based antiviral treatment was estimated to avert 14-23% of hospitalizations in an overall population of 62.28 million. Higher proportions of averted outcomes were seen in patients with high-risk conditions, when compared to non-high-risk patients. We found that antiviral treatment was cost-saving across pandemic scenarios for high-risk population groups, and cost-saving for the overall population in higher severity influenza pandemics. Antiviral effectiveness had the greatest influence on both the number of hospitalizations averted and on cost-effectiveness.

Conclusions: This analysis shows that across pandemic scenarios, antiviral treatment can be cost-saving for population groups at high risk of influenza-related complications.
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http://dx.doi.org/10.1093/pubmed/fdy108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7313872PMC
June 2019

Cost-effectiveness of dog rabies vaccination programs in East Africa.

PLoS Negl Trop Dis 2018 05 23;12(5):e0006490. Epub 2018 May 23.

Division of Preparedness and Emerging Infections, National Center of Emerging & Zoonotic Diseases, CDC, Atlanta, Georgia, United States of America.

Background: Dog rabies annually causes 24,000-70,000 deaths globally. We built a spreadsheet tool, RabiesEcon, to aid public health officials to estimate the cost-effectiveness of dog rabies vaccination programs in East Africa.

Methods: RabiesEcon uses a mathematical model of dog-dog and dog-human rabies transmission to estimate dog rabies cases averted, the cost per human rabies death averted and cost per year of life gained (YLG) due to dog vaccination programs (US 2015 dollars). We used an East African human population of 1 million (approximately 2/3 living in urban setting, 1/3 rural). We considered, using data from the literature, three vaccination options; no vaccination, annual vaccination of 50% of dogs and 20% of dogs vaccinated semi-annually. We assessed 2 transmission scenarios: low (1.2 dogs infected per infectious dog) and high (1.7 dogs infected). We also examined the impact of annually vaccinating 70% of all dogs (World Health Organization recommendation for dog rabies elimination).

Results: Without dog vaccination, over 10 years there would a total of be approximately 44,000-65,000 rabid dogs and 2,100-2,900 human deaths. Annually vaccinating 50% of dogs results in 10-year reductions of 97% and 75% in rabid dogs (low and high transmissions scenarios, respectively), approximately 2,000-1,600 human deaths averted, and an undiscounted cost-effectiveness of $451-$385 per life saved. Semi-annual vaccination of 20% of dogs results in in 10-year reductions of 94% and 78% in rabid dogs, and approximately 2,000-1,900 human deaths averted, and cost $404-$305 per life saved. In the low transmission scenario, vaccinating either 50% or 70% of dogs eliminated dog rabies. Results were most sensitive to dog birth rate and the initial rate of dog-to-dog transmission (Ro).

Conclusions: Dog rabies vaccination programs can control, and potentially eliminate, dog rabies. The frequency and coverage of vaccination programs, along with the level of dog rabies transmission, can affect the cost-effectiveness of such programs. RabiesEcon can aid both the planning and assessment of dog rabies vaccination programs.
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http://dx.doi.org/10.1371/journal.pntd.0006490DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5988334PMC
May 2018

Impact of a Hypothetical Infectious Disease Outbreak on US Exports and Export-Based Jobs.

Health Secur 2018 Jan/Feb;16(1):1-7. Epub 2018 Feb 6.

We estimated the impact on the US export economy of an illustrative infectious disease outbreak scenario in Southeast Asia that has 3 stages starting in 1 country and, if uncontained, spreads to 9 countries. We used 2014-2016 West Africa Ebola epidemic-related World Bank estimates of 3.3% and 16.1% reductions in gross domestic product (GDP). We also used US Department of Commerce job data to calculate export-related jobs at risk to any outbreak-related disruption in US exports. Assuming a direct correlation between GDP reductions and reduced demand for US exports, we estimated that the illustrative outbreak would cost from $16 million to $27 million (1 country) to $10 million to $18 billion (9 countries) and place 1,500 to almost 1.4 million export-related US jobs at risk. Our analysis illustrates how global health security is enhanced, and the US economy is protected, when public health threats are rapidly detected and contained at their source.
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http://dx.doi.org/10.1089/hs.2017.0052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5815448PMC
October 2018

The Epidemiology of Foodborne Botulism Outbreaks: A Systematic Review.

Clin Infect Dis 2017 12;66(suppl_1):S73-S81

Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.

Background: We performed a systematic review of foodborne botulism outbreaks to describe their clinical aspects and descriptive epidemiology in order to inform public health response strategies.

Methods: We searched seven databases for reports of foodborne botulism outbreaks published in English from database inception to May 2015. We summarized descriptive characteristics and analyzed differences in exposure and toxin types by geographic region. We performed logistic regression to assess correlations between exposure source, implicated food, and outbreak size.

Results: There were 197 outbreaks reported between 1920 and 2014. The median number of cases per outbreak was 3 (range 2-97). The majority of reported outbreaks (109; 55%) occurred in the United States. Toxin types A, B, E, and F were identified as the causative agent in 34%, 16%, 17%, and 1% of outbreaks, respectively. The median duration between exposure and symptom onset was approximately 1 day. The mean percentage of cases requiring mechanical ventilation per outbreak was 34%. Seventy percent of all outbreaks and 77% of small outbreaks (≤11 cases) originated from point source exposures, while commercial foods were significantly (odds ratio, 6.9; 95% confidence interval, 2.2-21.1) associated with large outbreaks (≥12 cases).

Conclusions: Toxin type A accounted for half of outbreaks, and these outbreaks had a higher proportion of patient ventilatory failure. Most outbreaks were due to point source exposures, while outbreaks due to commercial food were larger. For effective responses to foodborne botulism outbreaks, these findings demonstrate the need for timely outbreak investigation and hospital surge capacity.
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http://dx.doi.org/10.1093/cid/cix846DOI Listing
December 2017

Relevance of Global Health Security to the US Export Economy.

Health Secur 2017 Nov/Dec;15(6):563-568. Epub 2017 Dec 4.

To reduce the health security risk and impact of outbreaks around the world, the US Centers for Disease Control and Prevention and its partners are building capabilities to prevent, detect, and contain outbreaks in 49 global health security priority countries. We examine the extent of economic vulnerability to the US export economy posed by trade disruptions in these 49 countries. Using 2015 US Department of Commerce data, we assessed the value of US exports and the number of US jobs supported by those exports. US exports to the 49 countries exceeded $308 billion and supported more than 1.6 million jobs across all US states in agriculture, manufacturing, mining, oil and gas, services, and other sectors. These exports represented 13.7% of all US export revenue worldwide and 14.3% of all US jobs supported by all US exports. The economic linkages between the United States and these global health security priority countries illustrate the importance of ensuring that countries have the public health capacities needed to control outbreaks at their source before they become pandemics.
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http://dx.doi.org/10.1089/hs.2017.0051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734155PMC
July 2018

Potential for broad-scale transmission of Ebola virus disease during the West Africa crisis: lessons for the Global Health security agenda.

Infect Dis Poverty 2017 Dec 1;6(1):159. Epub 2017 Dec 1.

National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

Background: The 2014-2016 Ebola crisis in West Africa had approximately eight times as many reported deaths as the sum of all previous Ebola outbreaks. The outbreak magnitude and occurrence of multiple Ebola cases in at least seven countries beyond Liberia, Sierra Leone, and Guinea, hinted at the possibility of broad-scale transmission of Ebola.

Main Text: Using a modeling tool developed by the US Centers for Disease Control and Prevention during the Ebola outbreak, we estimated the number of Ebola cases that might have occurred had the disease spread beyond the three countries in West Africa to cities in other countries at high risk for disease transmission (based on late 2014 air travel patterns). We estimated Ebola cases in three scenarios: a delayed response, a Liberia-like response, and a fast response scenario. Based on our estimates of the number of Ebola cases that could have occurred had Ebola spread to other countries beyond the West African foci, we emphasize the need for improved levels of preparedness and response to public health threats, which is the goal of the Global Health Security Agenda. Our estimates suggest that Ebola could have potentially spread widely beyond the West Africa foci, had local and international health workers and organizations not committed to a major response effort. Our results underscore the importance of rapid detection and initiation of an effective, organized response, and the challenges faced by countries with limited public health systems. Actionable lessons for strengthening local public health systems in countries at high risk of disease transmission include increasing health personnel, bolstering primary and critical healthcare facilities, developing public health infrastructure (e.g. laboratory capacity), and improving disease surveillance. With stronger local public health systems infectious disease outbreaks would still occur, but their rapid escalation would be considerably less likely, minimizing the impact of public health threats such as Ebola.

Conclusions: The Ebola outbreak could have potentially spread to other countries, where limited public health surveillance and response capabilities may have resulted in additional foci. Health security requires robust local health systems that can rapidly detect and effectively respond to an infectious disease outbreak.
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http://dx.doi.org/10.1186/s40249-017-0373-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710062PMC
December 2017

School-Based Influenza Vaccination: Health and Economic Impact of Maine's 2009 Influenza Vaccination Program.

Health Serv Res 2017 12;52 Suppl 2:2307-2330

Centers for Disease Control and Prevention, Atlanta, GA.

Objective: To estimate the societal economic and health impacts of Maine's school-based influenza vaccination (SIV) program during the 2009 A(H1N1) influenza pandemic.

Data Sources: Primary and secondary data covering the 2008-09 and 2009-10 influenza seasons.

Study Design: We estimated weekly monovalent influenza vaccine uptake in Maine and 15 other states, using difference-in-difference-in-differences analysis to assess the program's impact on immunization among six age groups. We also developed a health and economic Markov microsimulation model and conducted Monte Carlo sensitivity analysis.

Data Collection: We used national survey data to estimate the impact of the SIV program on vaccine coverage. We used primary data and published studies to develop the microsimulation model.

Principal Findings: The program was associated with higher immunization among children and lower immunization among adults aged 18-49 years and 65 and older. The program prevented 4,600 influenza infections and generated $4.9 million in net economic benefits. Cost savings from lower adult vaccination accounted for 54 percent of the economic gain. Economic benefits were positive in 98 percent of Monte Carlo simulations.

Conclusions: SIV may be a cost-beneficial approach to increase immunization during pandemics, but programs should be designed to prevent lower immunization among nontargeted groups.
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http://dx.doi.org/10.1111/1475-6773.12786DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682124PMC
December 2017

Cost Evaluation of a Government-Conducted Oral Cholera Vaccination Campaign-Haiti, 2013.

Am J Trop Med Hyg 2017 Oct;97(4_Suppl):37-42

Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Atlanta, Georgia.

The devastating 2010 cholera epidemic in Haiti prompted the government to introduce oral cholera vaccine (OCV) in two high-risk areas of Haiti. We evaluated the direct costs associated with the government's first vaccine campaign implemented in August-September 2013. We analyzed data for major cost categories and assessed the efficiency of available campaign resources to vaccinate the target population. For a target population of 107,906 persons, campaign costs totaled $624,000 and 215,295 OCV doses were dispensed. The total vaccine and operational cost was $2.90 per dose; vaccine alone cost $1.85 per dose, vaccine delivery and administration $0.70 per dose, and vaccine storage and transport $0.35 per dose. Resources were greater than needed-our analyses suggested that approximately 2.5-6 times as many persons could have been vaccinated during this campaign without increasing the resources allocated for vaccine delivery and administration. These results can inform future OCV campaigns in Haiti.
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http://dx.doi.org/10.4269/ajtmh.16-1023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5676633PMC
October 2017

Cost-Effectiveness Evaluation of a Novel Integrated Bite Case Management Program for the Control of Human Rabies, Haiti 2014-2015.

Am J Trop Med Hyg 2017 Jun;96(6):1307-1317

Poxvirus and Rabies Branch, Division of High Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.

AbstractHaiti has the highest burden of rabies in the Western hemisphere, with 130 estimated annual deaths. We present the cost-effectiveness evaluation of an integrated bite case management program combining community bite investigations and passive animal rabies surveillance, using a governmental perspective. The Haiti Animal Rabies Surveillance Program (HARSP) was first implemented in three communes of the West Department, Haiti. Our evaluation encompassed all individuals exposed to rabies in the study area ( = 2,289) in 2014-2015. Costs (2014 U.S. dollars) included diagnostic laboratory development, training of surveillance officers, operational costs, and postexposure prophylaxis (PEP). We used estimated deaths averted and years of life gained (YLG) from prevented rabies as health outcomes. HARSP had higher overall costs (range: $39,568-$80,290) than the no-bite-case-management (NBCM) scenario ($15,988-$26,976), partly from an increased number of bite victims receiving PEP. But HARSP had better health outcomes than NBCM, with estimated 11 additional annual averted deaths in 2014 and nine in 2015, and 654 additional YLG in 2014 and 535 in 2015. Overall, HARSP was more cost-effective (US$ per death averted) than NBCM (2014, HARSP: $2,891-$4,735, NBCM: $5,980-$8,453; 2015, HARSP: $3,534-$7,171, NBCM: $7,298-$12,284). HARSP offers an effective human rabies prevention solution for countries transitioning from reactive to preventive strategies, such as comprehensive dog vaccination.
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http://dx.doi.org/10.4269/ajtmh.16-0785DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5462564PMC
June 2017
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