Echinococcosis: An Economic Evaluation of a Veterinary Public Health Intervention in Rural Canada

Echinococcosis is a rare but endemic condition in people in Canada, caused by a zoonotic cestode for which the source of human infection is ingestion of parasite eggs shed by canids. The objectives of this study were to identify risk factors associated with infection and to measure the cost-utility of introducing an echinococcosis prevention program in a rural area. We analyzed human case reports submitted to the Canadian Institutes for Health Information between 2002 and 2011. Over this 10 year period, there were 48 cases associated with E. granulosus/E. canadensis, 16 with E. multilocularis, and 251 cases of echinococcosis for which species was not identified (total 315 cases). Nationally, annual incidence of echinococcosis was 0.14 cases per 100 000 people, which is likely an underestimate due to under-diagnosis and under-reporting. Risk factors for echinococcosis included female gender, age (>65 years), and residing in one of the northern territories (Nunavut, Yukon, or Northwest Territories). The average cost of treating a case of cystic echinococcosis in Canada was $8,842 CAD. Cost-utility analysis revealed that dosing dogs with praziquantel (a cestocide) at six week intervals to control cystic echinococcosis is not currently cost-effective at a threshold of $20,000-100,000 per Quality Adjusted Life Year (QALY) gained, even in a health region with the highest incidence rate in Canada ($666,978 -755,051 per QALY gained). However, threshold analysis demonstrated that the program may become cost-saving at an echinococcosis incidence of 13-85 cases per 100,000 people and therefore, even one additional CE case in a community of 9000 people could result in the monetary benefits of the program outweighing costs.     

Conceptual framework and rationale

The sterile insect technique (SIT) has been shown to be an effective and sustainable genetic approach to control populations of selected major pest insects, when part of area-wide integrated pest management (AW-IPM) programmes. The technique introduces genetic sterility in females of the target population in the field following their mating with released sterile males. This process results in population reduction or elimination via embryo lethality caused by dominant lethal mutations induced in sperm of the released males. In the past, several field trials have been carried out for mosquitoes with varying degrees of success. New technology and experience gained with other species of insect pests has encouraged a reassessment of the use of the sterility principle as part of integrated control of malaria vectors. Significant technical and logistic hurdles will need to be overcome to develop the technology and make it effective to suppress selected vector populations, and its application will probably be limited to specific ecological situations. Using sterile males to control mosquito vector populations can only be effective as part of an AW-IPM programme. The area-wide concept entails the targeting of the total mosquito population within a defined area. It requires, therefore, a thorough understanding of the target pest population biology especially as regards mating behaviour, population dynamics, dispersal and level of reproductive isolation. The key challenges for success are: 1) devising methods to monitor vector populations and measuring competitiveness of sterile males in the field, 2) designing mass rearing, sterilization and release strategies that maintain competitiveness of the sterile male mosquitoes, 3) developing methods to separate sexes in order to release only male mosquitoes and 4) adapting suppression measures and release rates to take into account the high reproductive rate of mosquitoes. Finally, success in area-wide implementation in the field can only be achieved if close attention is paid to political, socio-economic and environmental sensitivities and an efficient management organization is established taking into account the interests of all potential stakeholders of an AW-IPM programme.     

The Potential Cost and Benefits of Raltegravir in Simplified Second-Line Therapy among HIV Infected Patients in Nigeria and South Africa

Background

There is an urgent need to improve the evidence base for provision of second-line antiretroviral therapy (ART) following first-line virological failure. This is particularly the case in Sub-Saharan Africa where 70% of all people living with HIV/AIDS (PHA) reside. The aim of this study was to simulate the potential risks and benefits of treatment simplification in second-line therapy compared to the current standard of care (SOC) in a lower-middle income and an upper-middle income country in Sub-Saharan Africa.

Methods

We developed a microsimulation model to compare outcomes associated with reducing treatment discontinuations between current SOC for second-line therapy in South Africa and Nigeria and an alternative regimen: ritonavir-boosted lopinavir (LPV/r) combined with raltegravir (RAL). We used published studies and collaborating sites to estimate efficacy, adverse effect and cost. Model outcomes were reported as incremental cost effectiveness ratios (ICERs) in 2011 USD per quality adjusted life year ($/QALY) gained.

Results

Reducing treatment discontinuations with LPV/r+RAL resulted in an additional 0.4 discounted QALYs and increased the undiscounted life expectancy by 0.8 years per person compared to the current SOC. The average incremental cost was $6,525 per treated patient in Nigeria and $4,409 per treated patient in South Africa. The cost-effectiveness ratios were $16,302/QALY gained and $11,085/QALY gained for Nigeria and South Africa, respectively. Our results were sensitive to the probability of ART discontinuation and the unit cost for RAL.

Conclusions

The combination of raltegravir and ritonavir-boosted lopinavir was projected to be cost-effective in South Africa. However, at its current price, it is unlikely to be cost-effective in Nigeria.     

Comparison of adult mosquito community structure on various habitats

The community structure of adult mosquitoes was compared from New Jersey light trap collections in six different types of habitats in Citrus County, Florida, USA. From October 1998 to December 2000, mosquitoes were collected three times a week from the following habitats (swamps, swamps and freshwater marshes, pine fiat-woods, pine fiat-woods and scrub, salt marshes, and salt marshes and mangroves). Mosquito density was highest in the swamps and freshwater marshes habitat, with an average of 95.65 specimens per trap.Density was lowest in the flatwoods and scrub habitat, with an average of 14.38 specimens per trap. Species dominance differed among habitats. Salt marshes produced the greatest aggregation index, while pine flatwoods produced the lowest. Conversely, diversity analysis showed that pine flatwoods had the greatest diversity, while salt marshes the lowest diversity. Similarity indices indicated that the adult mosquito communities from pine flatwoods and pine flatwoods and scrub were very similar (0.8583). The adult mosquito community of salt marshes was different from that of swamps and freshwater marshes (the similar index was 0.0217).     

Cost effectiveness analysis of a randomised trial of acupuncture for chronic headache in primary care

Objective To evaluate the cost effectiveness of acupuncture in the management of chronic headache.Design Cost effectiveness analysis of a randomised controlled trial.Setting General practices in England and Wales.Participants 401 patients with chronic headache, predominantly migraine.Interventions Patients were randomly allocated to receive up to 12 acupuncture treatments over three months from appropriately trained physiotherapists, or to usual care alone.Main outcome measure Incremental cost per quality adjusted life year (QALY) gained.Results Total costs during the one year period of the study were on average higher for the acupuncture group (£403; $768; €598) than for controls (£217) because of the acupuncture practitioners'' costs. The mean health gain from acupuncture during the one year of the trial was 0.021 quality adjusted life years (QALYs), leading to a base case estimate of £9180 per QALY gained. This result was robust to sensitivity analysis. Cost per QALY dropped substantially when the analysis incorporated likely QALY differences for the years after the trial.Conclusions Acupuncture for chronic headache improves health related quality of life at a small additional cost; it is relatively cost effective compared with a number of other interventions provided by the NHS.     

Population dynamics of Aedes aegypti and dengue as influenced by weather and human behavior in San Juan, Puerto Rico

Previous studies on the influence of weather on Aedes aegypti dynamics in Puerto Rico suggested that rainfall was a significant driver of immature mosquito populations and dengue incidence, but mostly in the drier areas of the island. We conducted a longitudinal study of Ae. aegypti in two neighborhoods of the metropolitan area of San Juan city, Puerto Rico where rainfall is more uniformly distributed throughout the year. We assessed the impacts of rainfall, temperature, and human activities on the temporal dynamics of adult Ae. aegypti and oviposition. Changes in adult mosquitoes were monitored with BG-Sentinel traps and oviposition activity with CDC enhanced ovitraps. Pupal surveys were conducted during the drier and wetter parts of the year in both neighborhoods to determine the contribution of humans and rains to mosquito production. Mosquito dynamics in each neighborhood was compared with dengue incidence in their respective municipalities during the study. Our results showed that: 1. Most pupae were produced in containers managed by people, which explains the prevalence of adult mosquitoes at times when rainfall was scant; 2. Water meters were documented for the first time as productive habitats for Ae. aegypti; 3. Even though Puerto Rico has a reliable supply of tap water and an active tire recycling program, water storage containers and discarded tires were important mosquito producers; 4. Peaks in mosquito density preceded maximum dengue incidence; and 5. Ae. aegypti dynamics were driven by weather and human activity and oviposition was significantly correlated with dengue incidence.     

HIV screening via fourth-generation immunoassay or nucleic acid amplification test in the United States: a cost-effectiveness analysis

Background

At least 10% of the 56,000 annual new HIV infections in the United States are caused by individuals with acute HIV infection (AHI). It unknown whether the health benefits and costs of routine nucleic acid amplification testing (NAAT) are justified, given the availability of newer fourth-generation immunoassay tests.

Methods

Using a dynamic HIV transmission model instantiated with U.S. epidemiologic, demographic, and behavioral data, I estimated the number of acute infections identified, HIV infections prevented, quality-adjusted life years (QALYs) gained, and the cost-effectiveness of alternative screening strategies. I varied the target population (everyone aged 15-64, injection drug users [IDUs] and men who have sex with men [MSM], or MSM only), screening frequency (annually, or every six months), and test(s) utilized (fourth-generation immunoassay only, or immunoassay followed by pooled NAAT).

Results

Annual immunoassay testing of MSM reduces incidence by 9.5% and costs <$10,000 per QALY gained. Adding pooled NAAT identifies 410 AHI per year, prevents 9.6% of new cases, costs $92,000 per QALY gained, and remains <$100,000 per QALY gained in settings where undiagnosed HIV prevalence exceeds 4%. Screening IDUs and MSM annually with fourth-generation immunoassay reduces incidence by 13% with cost-effectiveness <$10,000 per QALY gained. Increasing the screening frequency to every six months reduces incidence by 11% (MSM only) or 16% (MSM and IDUs) and costs <$20,000 per QALY gained.

Conclusions

Pooled NAAT testing every 12 months of MSM and IDUs in the United States prevents a modest number of infections, but may be cost-effective given sufficiently high HIV prevalence levels. However, testing via fourth-generation immunoassay every six months prevents a greater number of infections, is more economically efficient, and may obviate the benefits of acute HIV screening via NAAT.     

The Cost-Effectiveness Analysis of Teleglaucoma Screening Device

Glaucoma is the leading cause of irreversible vision loss and costs the American economy $2.9 billion. Teleglaucoma remotely detects glaucoma improving access to ophthalmic care in rural areas. It helps manage glaucoma more efficiently to preserve vision and reduce healthcare costs. A cost-effectiveness analysis was conducted using healthcare provider or third-party payer perspective within rural Canada. The study population were patients at-risk of glaucoma which includes those with diabetes and/or hypertension, family history of glaucoma, adults older than 50 years, and concurrent ocular conditions in rural Alberta. Markov modelling was used to model glaucoma health states. Effectiveness was measured in Quality-Adjusted Life Years (QALYs) and costs were used in Canadian dollars. Using TreeAge Pro 2009, incremental cost-effectiveness ratios (ICER) were developed in dollars per QALYs. Deterministic and probabilistic sensitivity analyses were performed to assess the factors affecting cost-effectiveness. Teleglaucoma had a 20% increase in ophthalmologist-referral rate; it reduced patient travel times by 61 hours and physician wait times by 30% in comparison to in-person examination (standard of care). Teleglaucoma costs $872 per patient screened which was 80% less than in-person examination. Teleglaucoma had a greater incremental effectiveness providing an additional 0.12 QALY per patient examination. It was more sensitive (86.5%) and less specific (78.6%) than in-person examination. Teleglaucoma was more cost-effective than in-person examination with an ICER of-$27,460/QALY. This indicated that teleglaucoma will save $27, 460 for each additional QALY gained. Long term benefits showed teleglaucoma prevents 24% cases of glaucoma blindness after 30 years. Teleglaucoma demonstrated improved health outcomes, as well as, cost benefits. It increases access to ophthalmic care and improves healthcare service efficiency, specifically in rural areas. Teleglaucoma is more cost-effective than current in-person examination and can improve the quality of life in glaucoma patients.     

The Identification of Plasmodium vivax Infected Anopheles sinensis by Enzyme-Linked Immunosorbent Assay, Republic of Korea, 1998

ABSTRACT To figure out how far spread the malaria parasite infected mosquitoes from Demilitarized Zone (DMZ). We investigated the sporozoite-infected mosquitoes in Chosan-ri and Hajiseok-ri of Paju-shi, Tonae-dong of Koyang-shi, Mudeung-ri of Yonchon-gun, Soyo-dong of Tongduchon-shi, and Tukjeong-ri of Yangju-gun, Kyonggi-do province in 1998. They were known as highly epidemic areas in the Republic of Korea. Anopheline mosquitoes were collected by human biting collection method from the 2nd week of June to the 5th week of August. A total of 3,256 anopheles mosquitoes were captured in these areas. A sandwich enzyme-linked immununosorbent assay (ELISA) for identifying Plasmodium vivax sporozoites in mosquitoes was used in this survey. Only one mosquito which was captured in Chosan-ri, on 2nd week of July showed positive reaction in this test. This mosquito was identified as Anopheles sinensis. This showed a 0.068% (1/1,465) positive rate in Chosan-ri on 2nd week of July. We could not detect positive mosquitoes the other areas. So we concluded the parasite infected mosquitoes may be highly limited near the DMZ.     

Nectar feeding by the early-spring mosquito Aedes provocans

Abstract. Nectar feeding by males and females of the mosquito Aedes provocans was studied at a site near Belleville, Ontario, Canada. Canada plum, Prunus nigra , and especially pin cherry, P. pensylvanica , bloomed contemporaneously with the emergence of Ae. provocans and were important nectar sources for adult mosquitoes during their first week of life. Blossoms of P. pensylvanica shielded for 24 h from foragers produced an average of 0.14 mg of sugar (≅ 2.3 J). This nectar was avidly sought by both sexes of Ae.provocans; > 97% of the blossoms were visited by mosquitoes in the first few days of blooming. Young adult mosquitoes were found on blossoms at all hours of the day and night; feeding on P. nigra was strongly eocrepuscular, whereas on P.pensylvanica feeding was much less strongly periodic. Adults foraged for nectar in an energy-conserving, pedestrian strategy, devoting 56% (females) and 68% (males) of their time on blossoms to nectar feeding during foraging bouts that lasted a median of 5.3min. Both sexes sought nectar soon after emergence - males before they had completed hypopygial rotation or swarmed, and females before mating or host seeking. Female Ae.provocans sought nectar in all stages of oogenesis, but primarily at the initiation of a gonotrophic cycle. Energy stores in the crop averaged 18 J per female, with a distribution that depended on gonotrophic age and parity.     

Distribution and seasonality of Culex (Melanoconion) caudelli, a vector of arboviruses in Trinidad

Seasonal and spatial distributions of the arbovirus vector mosquito Culex (Melanoconion) caudelli Dyar and Knab (Diptera: Culicidae) in the Aripo-Wallerfield forest, Trinidad, were studied by collecting mosquitoes attracted to mouse-baited traps in forest, ecotone and savannah, one day per week throughout the year, 98% of the Cx caudelli mosquitoes were collected during the wet season, with a significant positive correlation between rainfall and mosquito catch. The reverse occurred during the dry season. Cx caudelli displayed a preference for the ecotone where 67% were collected, while 32% and 1% were collected in the forest and savannah respectively.     

Dry-season Mosquito Breeding Associated with Irrigation in the Northeast Kimberley Region of Western Australia: Potential Impact on Mosquito-borne Disease Transmission

Recent Ross River virus activity prior to the onset of the wet season in the Kimberley region of Western Australia points to an increased dry season mosquito-borne disease risk at Kununurra, compared to other Kimberley towns. This study describes a preliminary investigation into the role of the Ord River Irrigation Area at Kununurra in mosquito production during the dry season. Specifically, the study sought to determine whether the irrigation area has provided the opportunity for year-round breeding of arbovirus vector mosquitoes. A 10-day adult and larval mosquito sampling survey, in August 2003, revealed that mosquito breeding was occurring during the driest month of the year at Kununurra, supporting the hypothesis that mosquitoes can breed year-round. Importantly, significantly larger numbers and percentage of adult Culex annulirostris, an important disease vector in Australia, were collected within the irrigation area (44.6% of total catch) compared to nearby reference (nonirrigated) breeding sites (9.8%) (mean difference 76.2 per trap per night; 95% CI 38.6, 113.7; P <0.001). Larval Cx. annulirostris were also collected at several sites within the irrigation area, whereas none were collected at reference sites. These results indicate that mosquito breeding associated with anthropogenic environmental changes may be responsible for an increased health risk at the end of the dry season. Mosquito management needs to be given a high priority to ensure this potential health risk is not further exacerbated. Several control strategies to reduce breeding of disease vector mosquitoes are identified, primarily focusing on modification of breeding habitats and alteration of irrigation protocols.     

A systematic review on the cost-effectiveness assessment of tisagenlecleucel for refractory or relapsing B-cell acute lymphoblastic leukemia (R/R B-ALL) treatment in children and young adults

Background aimsThe advanced therapy product tisagenlecleucel is a CD19-directed genetically modified autologous T-cell immunotherapy that has brought hope for children and young adults with relapsed/refractory (R/R) B-cell acute lymphoblastic leukemia (B-ALL). We sought to evaluate the cost-effectiveness of tisagenlecleucel compared with conventional salvage therapies in pediatric and young adult patients with R/R B-ALL.MethodsThis systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses parameters as registered in International Prospective Register of Systematic Reviews (CRD42021266998). Literature was searched using the MEDLINE databases via PubMed, EMBASE, Lilacs, the Cochrane Central Register of Controlled Trials and Web of Science in January 2022. Titles were screened independently by two reviewers. Articles deemed to meet the inclusion criteria were screened independently on abstract, and full texts were reviewed.ResultsIn total, 5627 publications were identified, from which six eligible studies were selected. The conventional therapies identified were blinatumomab (Blina), clofarabine monotherapy (Clo-M), clofarabine combined with cyclophosphamide and etoposide (Clo-C) and the combination of fludarabine, cytarabine and idarubicin (FLA-IDA). The discounted incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) gained for tisagenlecleucel compared with Clo-C and Blina averages was $38 837 and $25 569, respectively. In relation to the cost of the drug, the average of tisagenlecleucel was approximately 4.3 times, 10.8 times or 4.7 times greater than the Clo-M, Clo-C and Blina, respectively.ConclusionsThis systematic review highlighted that tisagenlecleucel is a much more expensive therapy than conventional alternatives. However, tisagenlecleucel performed well on the ICER, not exceeding $100 000/QALY. It was also found that the advanced therapy product was more effective than the conventional small molecule and biological drugs, in terms of life years and QALY gained.     

Nonionic contrast media: economic analysis and health policy development.

The replacement of old radiologic contrast media with supposedly safer but more expensive media has created a dilemma for radiologists and hospital administrators. To quantitate the nature of this trade-off we performed a cost-utility analysis using optimistic assumptions that favoured the new media. A complete conversion to the new media would result in an incremental cost of at least $65,000 to gain 1 quality-adjusted life-year (QALY). For a selective strategy in which only high-risk patients would receive the new media the cost would be about $23,000 per QALY gained. However, the incremental cost for low-risk patients is over $220,000 per QALY gained. Conversion to the new contrast media, although not necessarily the most efficient use of scarce resources, has already occurred in Ontario, primarily because of press publicity, pressure from insurers and a political unwillingness of policymakers to decide the fate of identifiable victims. We found that funding of a new intervention associated with a high cost-utility ratio rather than interventions with lower ratios might save some identifiable victims at the expense of a larger number of unidentifiable ones.     

Ecology and epizootology of Microsporidia in malarial mosquitoes (diptera: culicidae) from the south of Western Siberia

The ecology and epizootology of Microsporidia were studied in the natural population of malarial mosquitoes from Western Siberia over a 30-year period. Symptoms of the disease, host specificity and character of parasite localization in host tissues were investigated. Microsporidia of 9 species from 4 genera, namely Amblyospora, Crepidulospora, Senoma, and Parathelohania, were found in the malarial mosquito larvae from the territory examined. The mosquito species Anopheles messeae was infested by larger number of the microsporidian species, than A. beklemishevi. Spores and active stages of the microsporidian Senoma sp. from mosquito larvae are localized in epithelial cells of the host's intestine. There are no external signs of the infestation. The infested larvae do not die, and the infection proceeds to the pupal stage. Microsporidians of the genus Parathelohania infest larvae of both male and female mosquitoes. The parasites localized in the fat body cells. Body of the infested host gets an opaque white color in the period of spore maturation. The infested larvae perish at 4th stage. Microsporidian spores are formed in the mosquito larvae of both sexes. However, infection rate is much higher in the male larvae (77.8%), than that in the female larvae (22.2%). Symptoms of the disease under the infestation by the genera Crepidulospora and Amblyospora are similar to those under the infestation by Parathelohania sp. There are no external signs of the infestation in the adult mosquito females. In these hosts microsporidians form large two-nuclear spores with a thin capsule accounted for transovarial transmission. An about two times decrease of fertility in the Anopheles messeae females infested by the Parathelohania microsporidians is revealed. Mean number of eggs laid by the infested females was 121, while that of the noninfested ones was 232. Thus, the cause of the decrease in the mosquito abundance is both the elimination of male larvae and the decrease of fertility in females. In Siberia malarial mosquitoes yield 2 or 3 generations per year. Infested larvae are rarely occurred in the beginning of summer. Maximal extensiveness of the invasion may be observed in the end of summer, because of the accumulation of the infection in water bodies. Number of the peaks of infestation coincides with the peaks of abundance of mosquito larvae of 4th stage. Peaks of infestation are delayed as compared with the peaks of mosquito abundance. It is an evidence of the development delay in the infested larvae. Long-term dynamics of the infestation by microsporidians is studied. The epizooty caused by Parathelohania was observed in the malarial mosquitoes in the eighties (with the infestation rate up to 62 %). In the last ten years the infestation rate was low (from 0.1 to 2.6%).     

Larvivorous fishes fail to control mosquitoes in experimental rice plots

The individual and interactive effects of mosquitofish (Gambusia affinis Baird and Girard) and green sunfish (Lepomis cyanellus Rafinesque) populations on densities of mosquito immatures and other aquatic fauna were assessed in experimental rice plots over a 12 week period. Mosquitofish, stocked at a much higher rate (2318 per ha) than is usually used in commercial rice fields, increased 88-fold in numbers per minnow trap over a ten week period. Adult green sunfish (7–10 cm TL), stocked at the same rate as mosquitofish, reproduced in the rice plots, but reproductive success was strongly associated with plot depth. Mosquitofish numbers were significantly lower in plots stocked with green sunfish early in the season but this difference soon disappeared. Significant reductions in densities of the immature stages of the mosquito, Culex tarsalis Coquillet, by the fishes were not demonstrated by analyses of variance and covariance (mosquitofish may have provided some control during the very last week [Blaustein, 1990]). Populations of the mosquito, Anopheles freeborni Aitken, were not significantly reduced by mosquitofish except during the last week. A. freeborni populations were significantly higher in the green sunfish treatment than in the control and mosquitofish treatment. Numbers of notonectids (predators of mosquitoes) were depressed in all fish treatments. This may have indirectly contributed to the ineffectiveness of the fishes to control mosquitoes. Other invertebrate predators of mosquitoes were not reduced significantly by the fishes. Similarly, these fishes had little effect on microcrustaceans and chironomids. These fauna, by serving as alternative prey, may have reduced predation intensity on mosquitoes. These results demonstrate that high stocking rates and high population growth of mosquitofish will not necessarily provide control of mosquitoes in rice fields.     

Cost-Effectiveness of Treatment Strategies for BRAF-Mutated Metastatic Melanoma

Purpose

Genetically-targeted therapies are both promising and costly advances in the field of oncology. Several treatments for metastatic melanoma with a mutation in the BRAF gene have been approved. They extend life but are more expensive than the previous standard of care (dacarbazine). Vemurafenib, the first drug in this class, costs $13,000 per month ($207,000 for a patient with median survival). Patients failing vemurafenib are often given ipilimumab, an immunomodulator, at $150,000 per course. Assessment of cost-effectiveness is a valuable tool to help navigate the transition toward targeted cancer therapy.

Methods

We performed a cost-utility analysis to compare three strategies for patients with BRAF+ metastatic melanoma using a deterministic expected-value decision tree model to calculate the present value of lifetime costs and quality-adjusted life years (QALYs) for each strategy. We performed sensitivity analyses on all variables.

Results

In the base case, the incremental cost-effectiveness ratio (ICER) for vemurafenib compared with dacarbazine was $353,993 per QALY gained (0.42 QALYs added, $156,831 added). The ICER for vemurafenib followed by ipilimumab compared with vemurafenib alone was $158,139. In sensitivity analysis, treatment cost had the largest influence on results: the ICER for vemurafenib versus dacarbazine dropped to $100,000 per QALY gained with a treatment cost of $3600 per month.

Conclusion

The cost per QALY gained for treatment of BRAF+ metastatic melanoma with vemurafenib alone or in combination exceeds widely-cited thresholds for cost-effectiveness. These strategies may become cost-effective with lower drug prices or confirmation of a durable response without continued treatment.     

A Cost-Utility Analysis of Lung Cancer Screening and the Additional Benefits of Incorporating Smoking Cessation Interventions

Background

A 2011 report from the National Lung Screening Trial indicates that three annual low-dose computed tomography (LDCT) screenings for lung cancer reduced lung cancer mortality by 20% compared to chest X-ray among older individuals at high risk for lung cancer. Discussion has shifted from clinical proof to financial feasibility. The goal of this study was to determine whether LDCT screening for lung cancer in a commercially-insured population (aged 50–64) at high risk for lung cancer is cost-effective and to quantify the additional benefits of incorporating smoking cessation interventions in a lung cancer screening program.

Methods and Findings

The current study builds upon a previous simulation model to estimate the cost-utility of annual, repeated LDCT screenings over 15 years in a high risk hypothetical cohort of 18 million adults between age 50 and 64 with 30+ pack-years of smoking history. In the base case, the lung cancer screening intervention cost $27.8 billion over 15 years and yielded 985,284 quality-adjusted life years (QALYs) gained for a cost-utility ratio of $28,240 per QALY gained. Adding smoking cessation to these annual screenings resulted in increases in both the costs and QALYs saved, reflected in cost-utility ratios ranging from $16,198 per QALY gained to $23,185 per QALY gained. Annual LDCT lung cancer screening in this high risk population remained cost-effective across all sensitivity analyses.

Conclusions

The findings of this study indicate that repeat annual lung cancer screening in a high risk cohort of adults aged 50–64 is highly cost-effective. Offering smoking cessation interventions with the annual screening program improved the cost-effectiveness of lung cancer screening between 20% and 45%. The cost-utility ratios estimated in this study were in line with other accepted cancer screening interventions and support inclusion of annual LDCT screening for lung cancer in a high risk population in clinical recommendations.     

Programmatic review of the mosquito control methods used in the highly industrialized rice agroecosystems of Sacramento and Yolo Counties,California

In the Sacramento Valley (California, USA), rice (Oryza sativa L.) fields are an economically important crop and productive habitats for the mosquito species Culex tarsalis and Anopheles freeborni. Since 2010, approximately 150 km² of conventional and 16 km² of organic rice have been grown in Sacramento and Yolo Counties. These fields are often within mosquito flight-range of both rural towns and urban centers. Culex tarsalis are highly competent vectors of West Nile virus, and An. freeborni are aggressive, mammalophagic, nuisance biters. The Sacramento–Yolo Mosquito and Vector Control District provides mosquito control for the two counties in its jurisdiction. The principles of Integrated Pest Management are used to control mosquitoes in rice growing areas, relying upon a range of surveillance and control interventions. Larvae are controlled by limiting habitats that enable development of immature mosquitoes while balancing agricultural and wildlife needs, applying larvicides, and the use of Gambusia affinis (mosquitofish). Adult mosquitoes are controlled by ultra-low volume pesticide applications. The program was assessed for larval and adult mosquito control efficacy and areas of programmatic improvement identified. Because rice fields are productive habitats for mosquitoes, complete elimination of the habitat is not a feasible goal, thus efforts are aimed at interrupting disease transmission and reducing the number of mosquitoes that traverse into populated areas.

     

A cost-effectiveness analysis of off-label atypical antipsychotic treatment in children and adolescents with ADHD who have failed stimulant therapy

The objectives of this study are: (1) to estimate the expected health outcomes of atypical antipsychotics (AAPs) and other non-stimulant attention-deficit/hyperactivity disorder (ADHD) medications and (2) to evaluate the cost-effectiveness of AAPs compared to other non-stimulant ADHD medications. We used decision analysis to compare three alternatives for treating children and adolescents with ADHD who failed initial stimulant treatment: (1) AAPs, (2) a selective norepinephrine reuptake inhibitor (atomoxetine), and (3) selective α2-adrenergic agonists (clonidine and guanfacine). Probability estimates and quality-adjusted life year (QALY) weights were derived from a literature review. Cost-effectiveness was estimated using the expected health outcomes derived from the decision analysis and expected costs from the literature. The study was conducted from the third-party payer perspective, and the study period was 1 year. One-way deterministic sensitivity analysis and a Monte Carlo simulation were performed. Over the course of 1 year of ADHD pharmacotherapy, the highest QALY was for clonidine/guanfacine (expected QALY = 0.95) followed by atomoxetine (expected QALY = 0.94). Atypical antipsychotics yielded the lowest health outcome with an expected QALY of 0.84. In the cost-effectiveness analysis, the AAP strategy was dominated as it was less effective and more costly than other two strategies. Compared to clonidine/guanfacine, AAPs provided lower QALYs (0.11 QALY lost) at an additional cost of $2186 on average. Compared to atomoxetine, AAPs resulted in 0.10 QALYs lost at an additional cost of $2186. In this decision analysis model, AAPs provide lower expected health outcomes than other ADHD medications in children and adolescents who failed prior stimulant therapy. Furthermore, AAPs were not a cost-effective option.