Cost-effectiveness rankings of health interventions are useful inputs for national healthcare planning and budgeting. Previous comprehensive rankings for low- and middle- income countries were ...undertaken in 2005 and 2006, accompanying the development of strategies for the Millennium Development Goals. We update the rankings using studies published since 2000, as strategies are being considered for the Sustainable Development Goals.
Expert systematic searches of the literature were undertaken for a broad range of health interventions. Cost-effectiveness results using Disability Adjusted Life-Years (DALYs) as the health outcome were standardized to 2012 US dollars.
149 individual studies of 93 interventions qualified for inclusion. Interventions for Reproductive, Maternal, Newborn and Child Health accounted for 37% of interventions, and major infectious diseases (AIDS, TB, malaria and neglected tropical diseases) for 24%, consistent with the priorities of the Millennium Development Goals. More than half of the interventions considered cost less than $200 per DALY and hence can be considered for inclusion in Universal Health Care packages even in low-income countries.
Important changes have occurred in rankings since 2006. Priorities have changed as a result of new technologies, new methods for changing behavior, and significant price changes for some vaccines and drugs. Achieving the Sustainable Development Goals will require LMICs to study a broader range of health interventions, particularly in adult health. Some interventions are no longer studied, in some cases because they have become usual care, in other cases because they are no longer relevant. Updating cost-effectiveness rankings on a regular basis is potentially a valuable exercise.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Summary Investments in cancer control—prevention, detection, diagnosis, surgery, other treatment, and palliative care—are increasingly needed in low-income and particularly in middle-income ...countries, where most of the world's cancer deaths occur without treatment or palliation. To help countries expand locally appropriate services, Cancer (the third volume of nine in Disease Control Priorities , 3rd edition) developed an essential package of potentially cost-effective measures for countries to consider and adapt. Interventions included in the package are: prevention of tobacco-related cancer and virus-related liver and cervical cancers; diagnosis and treatment of early breast cancer, cervical cancer, and selected childhood cancers; and widespread availability of palliative care, including opioids. These interventions would cost an additional US$20 billion per year worldwide, constituting 3% of total public spending on health in low-income and middle-income countries. With implementation of an appropriately tailored package, most countries could substantially reduce suffering and premature death from cancer before 2030, with even greater improvements in later decades.
Summary Background The age-specific mortality rates and total deaths from specific cancers have not been documented for the various regions and subpopulations of India. We therefore assessed the ...cause of death in 2001–03 in homes in small areas that were chosen to be representative of all the parts of India. Methods At least 130 trained physicians independently assigned causes to 122 429 deaths, which occurred in 1·1 million homes in 6671 small areas that were randomly selected to be representative of all of India, based on a structured non-medical surveyor's field report. Findings 7137 of 122 429 study deaths were due to cancer, corresponding to 556 400 national cancer deaths in India in 2010. 395 400 (71%) cancer deaths occurred in people aged 30–69 years (200 100 men and 195 300 women). At 30–69 years, the three most common fatal cancers were oral (including lip and pharynx, 45 800 22·9%), stomach (25 200 12·6%), and lung (including trachea and larynx, 22 900 11·4%) in men, and cervical (33 400 17·1%), stomach (27 500 14·1%), and breast (19 900 10·2%) in women. Tobacco-related cancers represented 42·0% (84 000) of male and 18·3% (35 700) of female cancer deaths and there were twice as many deaths from oral cancers as lung cancers. Age-standardised cancer mortality rates per 100 000 were similar in rural (men 95·6 99% CI 89·6–101·7 and women 96·6 90·7–102·6) and urban areas (men 102·4 92·7–112·1 and women 91·2 81·9–100·5), but varied greatly between the states, and were two times higher in the least educated than in the most educated adults (men, illiterate 106·6 97·4–115·7 vs most educated 45·7 37·8–53·6; women, illiterate 106·7 99·9–113·6 vs most educated 43·4 30·7–56·1). Cervical cancer was far less common in Muslim than in Hindu women (study deaths 24, age-standardised mortality ratio 0·68 0·64–0·71 vs 340, 1·06 1·05–1·08). Interpretation Prevention of tobacco-related and cervical cancers and earlier detection of treatable cancers would reduce cancer deaths in India, particularly in the rural areas that are underserved by cancer services. The substantial variation in cancer rates in India suggests other risk factors or causative agents that remain to be discovered. Funding Bill & Melinda Gates Foundation and US National Institutes of Health.
India has a substantial burden of malaria, concentrated in specific areas and population groups. Spatio-temporal modelling of deaths due to malaria in India is a critical tool for identifying ...high-risk groups for effective resource allocation and disease control policy-making, and subsequently for the country's progress towards United Nations 2030 Sustainable Development Goals.
In this study, a spatio-temporal model with the objective of understanding the spatial distribution of malaria mortality rates and the rate of temporal decline, across the country, has been constructed. A spatio-temporal "random slope" model was used, with malaria risk depending on a spatial relative risk surface and a linear time effect with a spatially-varying coefficient. The models were adjusted for urban/rural status (residence of the deceased) and Normalized Difference Vegetation Index (NDVI), using 2004-13 data from the Million Death Study (MDS) (the most recent data available), with nationwide geographic coverage. Previous studies based on MDS had focused only on aggregated analyses.
The rural population had twice the risk of death due to malaria compared to the urban population. Malaria mortality in some of the highest-risk regions, namely the states of Odisha and Jharkhand, are declining faster than other areas; however, the rate of decline was not uniformly correlated with the level of risk. The overall decline was faster after 2010.
The results suggest a need for increased attention in high-risk rural populations, which already face challenges like inadequate infrastructure, inaccessibility to health care facilities, awareness, and education around malaria mortality and prevalence. It also points to the urgent need to restart the MDS to document changes since 2013, to develop appropriate malaria control measures.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
After a period of unprecedented progress against malaria in the 2000s, halving the global disease burden by 2015, gains overall in sub-Saharan Africa have slowed and even reversed in some places, ...beginning well before the COVID-19 pandemic. The highly effective drugs, treated nets, and diagnostics that fueled the initial progress all face some threats to their effectiveness, and global funding to maintain and increase their use over the long term is not guaranteed. Malaria vaccines are among the most promising new interventions that could accelerate the elimination of malaria. Vaccines are still in early stages of rollout in children, the age group (along with pregnant women) that has been the focus of malaria strategies for a century. At the same time, over the past decade, a case has been made, based largely on evidence from verbal autopsies in at least a few high-transmission areas, that the malaria death rate among adults has been greatly underestimated. Could vaccinating adults help to bring down the adult malaria mortality rate, contribute to reduced transmission, or both? A randomized trial of a malaria vaccine is proposed in Sierra Leone, a highly endemic setting, to shed light on this proposition.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Random population-based surveys to estimate prevalence of SARS-CoV2 infection causing coronavirus disease (COVID-19) are useful to understand distributions and predictors of the infection. In April ...2020, the first-ever nationally representative survey in Canada polled 4,240 adults age 18 years and older about self-reported COVID experience in March, early in the epidemic. We examined the levels and predictors of COVID symptoms, defined as fever plus difficulty breathing/shortness of breath, dry cough so severe that it disrupts sleep, and/or loss of sense of smell; and testing for SARS-CoV-2 by respondents and/or household members. About 8% of Canadians reported that they and/or one or more household members experienced COVID symptoms. Symptoms were more common in younger than in older adults, and among visible minorities. Overall, only 3% of respondents and/or household members reported testing for SARS-CoV-2. Being tested was associated with having COVID symptoms, Indigenous identity, and living in Quebec. Periodic nationally representative surveys of symptoms, as well as SARS-CoV-2 antibodies, are required in many countries to understand the pandemic and prepare for the future.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Antimicrobial resistance is a major contemporary public health threat. Strategies to contain antimicrobial resistance have been comprehensively set forth, however in developing countries where the ...need for effective antimicrobials is greatest implementation has proved problematic. A better understanding of patterns and determinants of antibiotic use and resistance in emerging economies may permit more appropriately targeted interventions.Viet Nam, with a large population, high burden of infectious disease and relatively unrestricted access to medication, is an excellent case study of the difficulties faced by emerging economies in controlling antimicrobial resistance.
Our working group conducted a situation analysis of the current patterns and determinants of antibiotic use and resistance in Viet Nam. International publications and local reports published between 1-1-1990 and 31-8-2012 were reviewed. All stakeholders analyzed the findings at a policy workshop and feasible recommendations were suggested to improve antibiotic use in Viet Nam.Here we report the results of our situation analysis focusing on: the healthcare system, drug regulation and supply; antibiotic resistance and infection control; and agricultural antibiotic use.
Market reforms have improved healthcare access in Viet Nam and contributed to better health outcomes. However, increased accessibility has been accompanied by injudicious antibiotic use in hospitals and the community, with predictable escalation in bacterial resistance. Prescribing practices are poor and self-medication is common - often being the most affordable way to access healthcare. Many policies exist to regulate antibiotic use but enforcement is insufficient or lacking.Pneumococcal penicillin-resistance rates are the highest in Asia and carbapenem-resistant bacteria (notably NDM-1) have recently emerged. Hospital acquired infections, predominantly with multi-drug resistant Gram-negative organisms, place additional strain on limited resources. Widespread agricultural antibiotic use further propagates antimicrobial resistance.
Future legislation regarding antibiotic access must alter incentives for purchasers and providers and ensure effective enforcement. The Ministry of Health recently initiated a national action plan and approved a multicenter health improvement project to strengthen national capacity for antimicrobial stewardship in Viet Nam. This analysis provided important input to these initiatives. Our methodologies and findings may be of use to others across the world tackling the growing threat of antibiotic resistance.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
India accounts for about a fifth of cardiovascular deaths globally, but nationally representative data on mortality trends are not yet available. In this nationwide mortality study, we aimed to ...assess the trends in ischaemic heart disease and stroke mortality over 15 years using the Million Death Study.
We determined national and subnational cardiovascular mortality rates and trends by sex and birth cohort using cause of death ascertained by verbal autopsy from 2001 to 2013 among 2·4 million households. We derived mortality rates for ischaemic heart disease and stroke by applying mortality proportions to UN mortality estimates for India and projected the rates from 2000 to 2015.
Cardiovascular disease caused more than 2·1 million deaths in India in 2015 at all ages, or more than a quarter of all deaths. At ages 30–69 years, of 1·3 million cardiovascular deaths, 0·9 million (68·4%) were caused by ischaemic heart disease and 0·4 million (28·0%) by stroke. At these ages, the probability of dying from ischaemic heart disease increased during 2000–15, from 10·4% to 13·1% in men and 4·8% to 6·6% in women. Ischaemic heart disease mortality rates in rural areas increased rapidly and surpassed those in urban areas. By contrast, the probability of dying from stroke decreased from 5·7% to 5·0% in men and 5·0% to 3·9% in women. A third of premature stroke deaths occurred in the northeastern states, inhabited by a sixth of India's population, where rates increased significantly and were three times higher than the national average. The increased mortality rates of ischaemic heart disease nationally and stroke in the northeastern states were higher in the cohorts of adults born in the 1970s onwards, than in earlier decades. A large and growing proportion of the ischaemic heart disease nationally and stroke deaths in high-burden states reported earlier diagnosis of cardiovascular disease, but low medication use.
The unexpectedly diverse patterns of cardiovascular mortality require investigation to identify the role of established and new cardiovascular risk factors. Secondary prevention with effective and inexpensive long-term treatment and adult smoking cessation could prevent substantial numbers of premature deaths. Without progress against the control of cardiovascular disease in India, global goals to reduce non-communicable diseases by 2030 will be difficult to achieve.
Fogarty International Center of the US National Institutes of Health, Dalla Lana School of Public Health, University of Toronto, Indian Council of Medical Research, and the Disease Control Priorities.
The current move to establish a global system for antimicrobial resistance (AMR) surveillance was born of the need for reliable data that would allow estimating the impact of AMR on public health and ...the economy, strengthen the evidence for acting, and point toward appropriate interventions. Surveillance represents an important component of the global action plan on AMR adopted by the 68th World Health Assembly and embodied in the World Health Organization’s developing Global Antimicrobial Resistance Surveillance System (GLASS). GLASS is partly predicated on reproducing programmes that have been successful in Europe and elsewhere, following a longstanding and often successful tradition of transferring public health strategies from richer to poorer countries. The main aim is to generate datasets for trend analysis and benchmarking across nations. This is an important and useful purpose, mainly to guide policy decisions and allocate resources where and when predictable threats to public health need to be addressed. At the same time, it should not be seen as a reason to delay the introduction of another layer that is already being added in Europe - whole genome sequencing (WGS) enrich our understanding of AMR evolution and spread and contribute practical information for local and national infection control and clinical guidance. Our view is that WGS-based surveillance could and should be developed now in Africa in parallel, and may actually produce informative results more quickly until the conventional approach renders authoritative and comparable data. Our rationale is explained in this article.
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