Cost of Preventing,Managing, and Treating Human Papillomavirus (HPV)-Related Diseases in Sweden before the Introduction of Quadrivalent HPV Vaccination

Objective

Costs associated with HPV-related diseases such as cervical dysplasia, cervical cancer, and genital warts have not been evaluated in Sweden. These costs must be estimated in order to determine the potential savings if these diseases were eradicated and to assess the combined cost-effectiveness of HPV vaccination and cervical cancer screening. The present study aimed to estimate prevention, management, and treatment costs associated with cervical dysplasia, cervical cancer, and genital warts from a societal perspective in Sweden in 2009, 1 year before the quadrivalent HPV vaccination program was implemented.

Methods and Materials

Data from the Swedish cervical cancer screening program was used to calculate the costs associated with prevention (cytological cervical cancer screening), management (colposcopy and biopsy following inadequate/abnormal cytological results), and treatment of CIN. Swedish official statistics were used to estimate treatment costs associated with cervical cancer. Published epidemiological data were used to estimate the number of incident, recurrent, and persistent cases of genital warts; a clinical expert panel assessed management and treatment procedures. Estimated visits, procedures, and use of medications were used to calculate the annual cost associated with genital warts.

Results

From a societal perspective, total estimated costs associated with cervical cancer and genital warts in 2009 were €106.6 million, of which €81.4 million (76%) were direct medical costs. Costs associated with prevention, management, and treatment of CIN were €74 million; screening and management costs for women with normal and inadequate cytology alone accounted for 76% of this sum. The treatment costs associated with incident and prevalent cervical cancer and palliative care were €23 million. Estimated costs for incident, recurrent and persistent cases of genital warts were €9.8 million.

Conclusion

Prevention, management, and treatment costs associated with cervical dysplasia, cervical cancer, and genital warts are substantial. Defining these costs is important for future cost-effectiveness analyses of the quadrivalent HPV vaccination program in Sweden.     

Modeling and Mapping of Atmospheric Mercury Deposition in Adirondack Park,New York

The Adirondacks of New York State, USA is a region that is sensitive to atmospheric mercury (Hg) deposition. In this study, we estimated atmospheric Hg deposition to the Adirondacks using a new scheme that combined numerical modeling and limited experimental data. The majority of the land cover in the Adirondacks is forested with 47% of the total area deciduous, 20% coniferous and 10% mixed. We used litterfall plus throughfall deposition as the total atmospheric Hg deposition to coniferous and deciduous forests during the leaf-on period, and wet Hg deposition plus modeled atmospheric dry Hg deposition as the total Hg deposition to the deciduous forest during the leaf-off period and for the non-forested areas year-around. To estimate atmospheric dry Hg deposition we used the Big Leaf model. The average atmospheric Hg deposition to the Adirondacks was estimated as 17.4 g m yr with a range of −3.7–46.0 g m yr. Atmospheric Hg dry deposition (370 kg yr) was found to be more important than wet deposition (210 kg yr) to the entire Adirondacks (2.4 million ha). The spatial pattern showed a large variation in atmospheric Hg deposition with scattered areas in the eastern Adirondacks having total Hg deposition greater than 30 μg m⁻² yr⁻¹, while the southwestern and the northern areas received Hg deposition ranging from 25–30 μg m⁻² yr⁻¹.     

Estimated benefit of increased vitamin D status in reducing the economic burden of disease in western Europe

Vitamin D has important benefits in reducing the risk of many conditions and diseases. Those diseases for which the benefits are well supported and that have large economic effects include many types of cancer, cardiovascular diseases, diabetes mellitus, several bacterial and viral infections, and autoimmune diseases such as multiple sclerosis. Europeans generally have low serum 25-hydroxyvitamin D [25(OH)D] levels owing to the high latitudes, largely indoor living, low natural dietary sources of vitamin D such as cold-water ocean fish, and lack of effective vitamin D fortification of food in most countries. Vitamin D dose–disease response relations were estimated from observational studies and randomized controlled trials. The reduction in direct plus indirect economic burden of disease was based on increasing the mean serum 25(OH)D level to 40 ng/mL, which could be achieved by a daily intake of 2000–3000 IU of vitamin D. For 2007, the reduction is estimated at €187,000 million/year. The estimated cost of 2000–3000 IU of vitamin D3/day along with ancillary costs such as education and testing might be about €10,000 million/year. Sources of vitamin D could include a combination of food fortification, supplements, and natural and artificial UVB irradiation, if properly acquired. Additional randomized controlled trials are warranted to evaluate the benefits and risks of vitamin D supplementation. However, steps to increase serum 25(OH)D levels can be implemented now based on what is already known.     

Future direct and indirect costs of obesity and the influence of gaining weight: Results from the MONICA/KORA cohort studies, 1995-2005

Over the last two decades, the prevalence of obesity has risen worldwide. As obesity is a confirmed risk factor for a number of diseases, its increasing prevalence nurtures the supposition that obesity may present a growing and significant economic burden to society.The objective of this study is to analyse the correlation between body mass index (BMI) and future direct and indirect costs, as well as the correlation between changing BMI and future in(direct) costs. Health care utilisation and productivity losses were based on data from 2581 participants aged 25-65 years (1994/95) from two cross-sectional, population-representative health surveys (MONICA/KORA-survey-S3 1994/95 and follow-up KORA-survey-F3 2004/05) in Augsburg, Germany.The predicted average adjusted total direct costs per year and per user were estimated to be €1029-(healthy weight), €1093-(overweight) and €1040-(obesity). There are significantly greater future costs in the utilisation of general practitioners per user and per year at higher obesity levels (€72; €75; €96).The average total direct costs per person for those who stay in the same BMI class are €982, €1000 and €973. An overweight participant who becomes obese incurs significant costs of internists of €160 compared with those who remain overweight (€124). An overweight user incurs indirect costs of €2474, compared with €2136 for those who remain a healthy weight.There is a trend for higher predicted (in)direct costs when people are overweight or obese compared with healthy weight persons 10 years earlier. Potential cost savings could be attained if preventive programs effectively targeted these individuals.     

LAT Software Induced Savings on Medical Costs of Alcohol Addicts' Care - Results from a Matched-Pairs Case-Control Study

Lesch Alcoholism Typology (LAT) is one of the most widely used clinical typologies of alcohol addiction. Study tested whether introduction of LAT software in clinical practice leaded to improved outcomes and reduced costs. Retrospective matched-pairs case-control cost comparison study was conducted at the Regional Addiction Center of the University Clinic in Serbia involving 250 patients during the four-year period. Mean relapse frequency followed by outpatient detoxification was 0.42±0.90 vs. 0.70±1.66 (LAT/non-LAT; p = 0.267). Adding relapses after inpatient treatment total mean-number of relapses per patient was 0.70±1.74 vs. 0.97±1.89 (LAT/non-LAT; p = 0.201). However, these relapse frequency differentials were not statistically significant. Total hospital costs of Psychiatry clinic based non-LAT addicts'' care (€54,660) were significantly reduced to €36,569 after initiation of LAT. Mean total cost per patient was reduced almost by half after initiation of LAT based treatment: €331±381 vs. €626±795 (LAT/non-LAT; p = 0.001). Mean cost of single psychiatry clinic admission among non-LAT treatment group was €320±330 (CI 95% 262–378) and among LAT €197±165 (CI 95% 168–226) (p = 0.019). Mean LAT software induced net savings on psychiatric care costs were €144 per patient. Total net savings on hospital care including F10 associated somatic co-morbidities amounted to €295 per patient. More sensitive diagnostic assessment and sub-type specific pharmacotherapy and psychotherapy following implementation of LAT software lead to significant savings on costs of hospital care.     

Freshwater wetlands: fertile grounds for the invasive Phragmites australis in a climate change context

Climate change will likely affect flooding regimes, which have a large influence on the functioning of freshwater riparian wetlands. Low water levels predicted for several fluvial systems make wetlands especially vulnerable to the spread of invaders, such as the common reed (Phragmites australis), one of the most invasive species in North America. We developed a model to map the distribution of potential germination grounds of the common reed in freshwater wetlands of the St. Lawrence River (Québec, Canada) under current climate conditions and used this model to predict their future distribution under two climate change scenarios simulated for 2050. We gathered historical and recent (remote sensing) data on the distribution of common reed stands for model calibration and validation purposes, then determined the parameters controlling the species establishment by seed. A two‐dimensional model and the identified parameters were used to simulate the current (2010) and future (2050) distribution of germination grounds. Common reed stands are not widespread along the St. Lawrence River (212 ha), but our model suggests that current climate conditions are already conducive to considerable further expansion (>16,000 ha). Climate change may also exacerbate the expansion, particularly if river water levels drop, which will expose large bare areas propitious to seed germination. This phenomenon may be particularly important in one sector of the river, where existing common reed stands could increase their areas by a factor of 100, potentially creating the most extensive reedbed complex in North America. After colonizing salt and brackishwater marshes, the common reed could considerably expand into the freshwater marshes of North America which cover several million hectares. The effects of common reed expansion on biodiversity are difficult to predict, but likely to be highly deleterious given the competitiveness of the invader and the biological richness of freshwater wetlands.     

Economic Impact of a triptan Rx-To-OTC Switch in Six EU Countries

Introduction

Triptans have been safely and effectively used in the management of migraine for more than fifteen years, and it seems reasonable to wonder what would be the economic impact of moving a specific triptan to OTC availability. The objective of this study was then to examine the economic impact of payer policies of a triptan Rx-to-OTC switch in six EU countries (France, UK, Spain, Italy, Germany and Poland).

Methods

A decision model was used to model the budgetary impact of a triptan Rx-to-OTC switch from the third-party payer (TPP) and the societal perspectives, using a one-year timeframe.

Results

From the TPP perspective, it is estimated that the current overall direct spending on the management of migraine attacks across the 6 EU Member States is €582 million annually, and that the savings would reach €75 million (13% of the overall direct economic burden of migraine). From the societal perspective, €86 million annually would be added.

Conclusions

Given evidence of effectiveness and safety, and given the potential savings, a triptan Rx-to-OTC switch is a reasonable public policy decision.     

Loss of aboveground forest biomass and landscape biomass variability in Missouri,US

Disturbance regimes and forests have changed over time in the eastern United States. We examined effects of historical disturbance (circa 1813 to 1850) compared to current disturbance (circa 2004 to 2008) on aboveground, live tree biomass (for trees with diameters ≥13 cm) and landscape variation of biomass in forests of the Ozarks and Plains landscapes in Missouri, USA. We simulated 10,000 one-hectare plots using random diameters generated from parameters of diameter distributions limited to diameters ≥13 cm and random densities generated from density estimates. Area-weighted mean biomass density (Mg/ha) for historical forests averaged 116 Mg/ha, ranging from 54 Mg/ha to 357 Mg/ha by small scale ecological subsections within Missouri landscapes. Area-weighted mean biomass density for current forests averaged 82 Mg/ha, ranging from 66 Mg/ha to 144 Mg/ha by ecological subsection for currently forested land. Biomass density of current forest was greater than historical biomass density for only 2 of 23 ecological subsections. Current carbon sequestration of 292 TgC on 7 million ha of forested land is less than half of the estimated historical total carbon sequestration of 693 TgC on 12 million ha. Cumulative tree cutting disturbances over time have produced forests that have less aboveground tree biomass and are uniform in biomass compared to estimates of historical biomass, which varied across Missouri landscapes. With continued relatively low rates of forest disturbance, current biomass per ha will likely increase to historical levels as the most competitive trees become larger in size and mean number of trees per ha decreases due to competition and self-thinning. Restoration of large diameter structure and forested extent of upland woodlands and floodplain forests could fulfill multiple conservation objectives, including carbon sequestration.     

The Cost-Effectiveness of Emergency Hormonal Contraception with Ulipristal Acetate versus Levonorgestrel for Minors in France

Objective

To evaluate the cost-effectiveness of ulipristal acetate and levonorgestrel in minors in France, and analyze whether it is worthwhile to provide ulipristal acetate to minors free of charge.

Methods

The cost-effectiveness of two emergency contraceptive methods was compared based on a decision-analytical model. Pregnancy rates, outcomes of unintended pregnancies, and resource utilization were derived from the literature. Resources and their costs were considered until termination or a few days after delivery. Deterministic and probabilistic sensitivity analyses were performed.

Results

The cost of an unintended pregnancy in a French minor is estimated to be 1,630 € (range 1,330 € – 1,803 €). Almost 4 million € (3.1 € – 13.7 € million) in unintended pregnancy spending in 2010 could have been saved by the use of ulipristal acetate instead of levonorgestrel. The incremental cost of ulipristal acetate compared to levonorgestrel is 3.30 € per intake, or 418 € per pregnancy avoided (intake within 72 hours). In the intake within 24 hours subgroup, ulipristal acetate was found to be more efficacious at a lower cost compared to levonorgestrel.

Conclusions

Ulipristal acetate dominates levonorgestrel when taken within 24 hours after unprotected intercourse, i.e., it is more effective at a lower cost. When taken within 72 hours, ulipristal acetate is a cost- effective alternative to levonorgestrel, given that the cost of avoiding an additional pregnancy with ulipristal acetate is less than the average cost of these pregnancies. In the light of these findings, it is worthwhile to provide free access to minors.     

A nitrogen budget for late-successional hillslope tabonuco forest, Puerto Rico

Nitrogen budgets of late successional forested stands and watersheds provide baseline data against which the effects of small- and large-scale disturbances may be measured. Using previously published data and supplemental new data on gaseous N loss, we construct a N budget for hillslope tabonuco forest (HTF) stands in Puerto Rico. HTF stands are subject to frequent hurricanes and landslides; here, we focus on N fluxes in the late phase of inter-disturbance forest development. N inputs from atmospheric deposition (4-6 kg N/ha/yr) are exceeded by N outputs from groundwater, gaseous N loss, and particulate N loss (6.3–15.7 kg N/ha/yr). Late-successional HTF stands also sequester N in their aggrading biomass (8 kg N/ha/yr), creating a total budget imbalance of 8.3–19.7 kg N/ha/yr. We surmise that this imbalance may be accounted for by unmeasured inputs from above- and belowground N-fixation and/or slow depletion of the large N pool in soil organic matter. Spatial and temporal variability, especially that associated with gaseous exchange and soil organic matter N-mineralization, constrain the reliability of this N budget.(Formerly Tamara J. Eklund)     

Prolonged conservative care versus early surgery in patients with sciatica from lumbar disc herniation: cost utility analysis alongside a randomised controlled trial

Objective To determine whether the faster recovery after early surgery for sciatica compared with prolonged conservative care is attained at reasonable costs.Design Cost utility analysis alongside a randomised controlled trial.Setting Nine Dutch hospitals.Participants 283 patients with sciatica for 6-12 weeks, caused by lumbar disc herniation.Interventions Six months of prolonged conservative care compared with early surgery.Main outcome measures Quality adjusted life years (QALYs) at one year and societal costs, estimated from patient reported utilities (UK and US EuroQol, SF-6D, and visual analogue scale) and diaries on costs (healthcare, patient’s costs, and productivity).Results Compared with prolonged conservative care, early surgery provided faster recovery, with a gain in QALYs according to the UK EuroQol of 0.044 (95% confidence interval 0.005 to 0.083), the US EuroQol of 0.032 (0.005 to 0.059), the SF-6D of 0.024 (0.003 to 0.046), and the visual analogue scale of 0.032 (−0.003 to 0.066). From the healthcare perspective, early surgery resulted in higher costs (difference €1819 (£1449; $2832), 95% confidence interval €842 to €2790), with a cost utility ratio per QALY of €41 000 (€14 000 to €430 000). From the societal perspective, savings on productivity costs led to a negligible total difference in cost (€−12, €−4029 to €4006).Conclusions Faster recovery from sciatica makes early surgery likely to be cost effective compared with prolonged conservative care. The estimated difference in healthcare costs was acceptable and was compensated for by the difference in absenteeism from work. For a willingness to pay of €40 000 or more per QALY, early surgery need not be withheld for economic reasons.Trial registration Current Controlled Trials ISRCTN 26872154.     

The Chikungunya epidemic on La Réunion Island in 2005-2006: a cost-of-illness study

Background

This study was conducted to assess the impact of chikungunya on health costs during the epidemic that occurred on La Réunion in 2005–2006.

Methodology/Principal Findings

From data collected from health agencies, the additional costs incurred by chikungunya in terms of consultations, drug consumption and absence from work were determined by a comparison with the expected costs outside the epidemic period. The cost of hospitalization was estimated from data provided by the national hospitalization database for short-term care by considering all hospital stays in which the ICD-10 code A92.0 appeared. A cost-of-illness study was conducted from the perspective of the third-party payer. Direct medical costs per outpatient and inpatient case were evaluated. The costs were estimated in Euros at 2006 values. Additional reimbursements for consultations with general practitioners and drugs were estimated as €12.4 million (range: €7.7 million–€17.1 million) and €5 million (€1.9 million–€8.1 million), respectively, while the cost of hospitalization for chikungunya was estimated to be €8.5 million (€5.8 million–€8.7 million). Productivity costs were estimated as €17.4 million (€6 million–€28.9 million). The medical cost of the chikungunya epidemic was estimated as €43.9 million, 60% due to direct medical costs and 40% to indirect costs (€26.5 million and €17.4 million, respectively). The direct medical cost was assessed as €90 for each outpatient and €2,000 for each inpatient.

Conclusions/Significance

The medical management of chikungunya during the epidemic on La Réunion Island was associated with an important economic burden. The estimated cost of the reported disease can be used to evaluate the cost/efficacy and cost/benefit ratios for prevention and control programmes of emerging arboviruses.     

N deposition, N transformation and N leaching in acid forest soils

Nitrogen deposition, mineralisation, uptake and leaching were measured on a monthly basis in the field during 2 years in six forested stands on acidic soils under mountainous climate. Studies were conducted in three Douglas-fir [Pseudotsuga menziesii (Mirb.) Franco] plantations (D20: 20 year; D40: 40 yr; D60: 60 yr) on abandoned croplands in the Beaujolais Mounts; and two spruce (Picea abies Karst.) plantations (S45: 45 yr; S90: 90 yr) and an old beech (Fagus sylvatica L.) stand (B150: 150 yr) on ancient forest soils in a small catchment in the Vosges Mountains. N deposition in throughfall varied between 7–8 kg ha^–1 year^–1 (D20, B150, S45) and 15–21 kg ha^–1 yr^–1 (S90, D40, D60). N in annual litterfall varied between 20–29 kg ha^–1 (D40, D60, S90), and 36–43 kg ha^–1 (D20, S45, B150). N leaching below root depth varied among stands within a much larger range, between 1–9 kg ha^–1 yr^–1 (B150, S45, D60) and 28–66 kg ha^–1 yr^–1 (D40, S90, D20), with no simple relationship with N deposition, or N deposition minus N storage in stand biomass. N mineralisation was between 57–121 kg ha^–1 yr^–1 (S45, D40, S90) and between 176–209 kg ha^–1 yr^–1 in (B150, D60 and D20). The amounts of nitrogen annually mineralised and nitrified were positively related. Neither general soil parameters, such as pH, soil type, base saturation and C:N ratio, nor deposition in throughfall or litterfall were simply related to the intensity of mineralisation and/or nitrification. When root uptake was not allowed, nitrate leaching increased by 11 kg ha^–1 yr^–1 at S45, 36 kg ha^–1 yr^–1 at S90 and between 69 and 91 kg ha^–1 yr^–1 at D20, D40, B150 and D60, in relation to the nitrification rates of each plot. From this data set and recent data from the literature, we suggest that: high nitrification and nitrate leaching in Douglas-fir soils was likely related to the former agricultural land use. High nitrification rate but very low nitrate leaching in the old beech soil was related to intense recycling of mineralised N by beech roots. Medium nitrification and nitrate leaching in the old spruce stand was related to the average level of N deposition and to the deposition and declining health of the stand. Very low nitrification and N leaching in the young spruce stand were considered representative of fast growing spruce plantations receiving low N deposition on acidic soils of ancient coniferous forests. Consequently, we suggest that past land use and fine root cycling (which is dependent on to tree species and health) should be taken into account to explain the variability in the relation between N deposition and leaching in forests.     

Rapid Liana Colonization along a Secondary Forest Chronosequence

Lianas (woody vines) can have profound effects on tree recruitment, growth, survival, and diversity in tropical forests. However, the dynamics of liana colonization soon after land abandonment are poorly understood, and thus it is unknown whether lianas alter tree regeneration early in succession. We examined the liana community in 43 forests that ranged from 1 to 31 yr old in central Panama to determine how fast lianas colonize young forests and how the liana community changes with forest succession. We found that lianas reached high densities early in succession, commonly exceeding 1000 stems/ha within the first 5 yr of forest regeneration. Lianas also increased rapidly during early succession in terms of basal area but did not show evidence of saturation within the 30 yr of our chronosequence. The relative contribution of lianas to total woody plant community in terms of basal area and density increased rapidly and reached a saturation point within 5 yr (basal area) to 15 yr (density) after land abandonment. Our data demonstrate that lianas recruit early and in high density in tropical forest regeneration, and thus lianas may have a large effect on the way in which secondary forests develop both early and throughout succession.     

Gastrointestinal and Respiratory Illness in Children That Do and Do Not Attend Child Day Care Centers: A Cost-of-Illness Study

Background

Gastrointestinal and respiratory diseases are major causes of morbidity for young children, particularly for those children attending child day care centers (DCCs). Although both diseases are presumed to cause considerable societal costs for care and treatment of illness, the extent of these costs, and the difference of these costs between children that do and do not attend such centers, is largely unknown.

Objective

Estimate the societal costs for care and treatment of episodes of gastroenteritis (GE) and influenza-like illness (ILI) experienced by Dutch children that attend a DCC, compared to children that do not attend a DCC.

Methods

A web-based monthly survey was conducted among households with children aged 0–48 months from October 2012 to October 2013. Households filled-in a questionnaire on the incidence of GE and ILI episodes experienced by their child during the past 4 weeks, on the costs related to care and treatment of these episodes, and on DCC arrangements. Costs and incidence were adjusted for socioeconomic characteristics including education level, nationality and monthly income of parents, number of children in the household, gender and age of the child and month of survey conduct.

Results

Children attending a DCC experienced higher rates of GE (aIRR 1.4 [95%CI: 1.2–1.9]) and ILI (aIRR: 1.4 [95%CI: 1.2–1.6]) compared to children not attending a DCC. The societal costs for care and treatment of an episode of GE and ILI experienced by a DCC-attending child were estimated at €215.45 [€115.69–€315.02] and €196.32 [€161.58–€232.74] respectively, twice as high as for a non-DCC-attending child. The DCC-attributable economic burden of GE and ILI for the Netherlands was estimated at €25 million and €72 million per year.

Conclusions

Although children attending a DCC experience only slightly higher rates of GE and ILI compared to children not attending a DCC, the costs involved per episode are substantially higher.     

High carbon storage and oxygen (O2) release potential of Mahagony (Swietenia macrophylla) woodlot plantation in Bangladesh

Woodlot plantation takes our attention nowadays because of having high wood value, biomass and carbon stock. It also has considerable potential for regulating climate change by sinking CO₂. This study investigated the market value of Swietenia macrophylla woodlots concerning the current carbon trade mechanism, local timber and oxygen value. The carbon-di-oxide equivalence (CO_2e) and release oxygen (O_{2 Release}) ranged from 125.5 to 1004.5 Mg/ha (mean 436.3 Mg/ha) and 91.25–730.26 Mg/ha (mean 317.2 Mg/ha), respectively. Form carbon trade, the Swietenia macrophylla woodlots owner will earn 4,285–34,470 BDT/ha (mean 14,900 BDT/ha). It also seemed that the present market value of release oxygen (O_{2 Release}) ranged from 3.2 to 25.5 million BDT/ha (average 11.1 million BDT/ha). However, the study area's average DBH, height, density, and basal area were 18.9 cm, 12.6 m, 1233 stem/ha, and 36.6 m²/ha, respectively. The above-ground biomass, below-ground biomass, and total biomass ranged from 45.9 to 389.7 Mg/ha (mean 166.5 Mg/ha), 22.5–157.7 Mg/ha (mean 71.2 Mg/ha), and 68.4–547.4 Mg/ha (mean 237.7 Mg/ha) correspondingly. Besides, the produced wood volume ranged from 64.95-1225.19 m³/ha (average 481.48 m³/ha). While the price of wood ranged from 0.8 to 15.14 million BDT/ha (mean 5.95 million BDT/ha). However, the above-ground, below-ground, and total carbon ranged 22.97–194.85 Mg/ha (mean 87.27 Mg/ha, 11.23–78.85 Mg/ha (35.61 Mg/ha), and 34.2–273.7 Mg/ha (118.89 Mg/ha) independently. Moreover, our three developed basal area-based allometric models are fit for calculating the carbon stock of Swietenia macrophylla woodlots. This study explores the potentiality of woodlots in Bangladesh. Policymakers should encourage the farmers to create more woodlots that actively participate in climate change mitigation.     

Towards a taxonomically unbiased European Union biodiversity strategy for 2030

Through the Habitats Directive (92/43/EEC) and the financial investments of the LIFE projects, Europe has become an experimental arena for biological conservation. With an estimated annual budget of €20 billion, the EU Biodiversity Strategy for 2030 has set an ambitious goal of classifying 30% of its land and sea territory as Protected Areas and ensuring no deterioration in conservation trends and the status of protected species. We analysed LIFE projects focused on animals from 1992 to 2018 and found that investment in vertebrates was six times higher than that for invertebrates (€970 versus €150 million), with birds and mammals alone accounting for 72% of species and 75% of the total budget. In relative terms, investment per species towards vertebrates has been 468 times higher than that for invertebrates. Using a trait-based approach, we show that conservation effort is primarily explained by species'' popularity rather than extinction risk or body size. Therefore, we propose a roadmap to achieve unbiased conservation targets for 2030 and beyond.     

Scaling up target regimens for tuberculosis preventive treatment in Brazil and South Africa: An analysis of costs and cost-effectiveness

BackgroundShorter, safer, and cheaper tuberculosis (TB) preventive treatment (TPT) regimens will enhance uptake and effectiveness. WHO developed target product profiles describing minimum requirements and optimal targets for key attributes of novel TPT regimens. We performed a cost-effectiveness analysis addressing the scale-up of regimens meeting these criteria in Brazil, a setting with relatively low transmission and low HIV and rifampicin-resistant TB (RR-TB) prevalence, and South Africa, a setting with higher transmission and higher HIV and RR-TB prevalence.Methods and findingsWe used outputs from a model simulating scale-up of TPT regimens meeting minimal and optimal criteria. We assumed that drug costs for minimal and optimal regimens were identical to 6 months of daily isoniazid (6H). The minimal regimen lasted 3 months, with 70% completion and 80% efficacy; the optimal regimen lasted 1 month, with 90% completion and 100% efficacy. Target groups were people living with HIV (PLHIV) on antiretroviral treatment and household contacts (HHCs) of identified TB patients. The status quo was 6H at 2019 coverage levels for PLHIV and HHCs. We projected TB cases and deaths, TB-associated disability-adjusted life years (DALYs), and costs (in 2020 US dollars) associated with TB from a TB services perspective from 2020 to 2035, with 3% annual discounting. We estimated the expected costs and outcomes of scaling up 6H, the minimal TPT regimen, or the optimal TPT regimen to reach all eligible PLHIV and HHCs by 2023, compared to the status quo. Maintaining current 6H coverage in Brazil (0% of HHCs and 30% of PLHIV treated) would be associated with 1.1 (95% uncertainty range [UR] 1.1–1.2) million TB cases, 123,000 (115,000–132,000) deaths, and 2.5 (2.1–3.1) million DALYs and would cost $1.1 ($1.0–$1.3) billion during 2020–2035. Expanding the 6H, minimal, or optimal regimen to 100% coverage among eligible groups would reduce DALYs by 0.5% (95% UR 1.2% reduction, 0.4% increase), 2.5% (1.8%–3.0%), and 9.0% (6.5%–11.0%), respectively, with additional costs of $107 ($95–$117) million and $51 ($41–$60) million and savings of $36 ($14–$58) million, respectively. Compared to the status quo, costs per DALY averted were $7,608 and $808 for scaling up the 6H and minimal regimens, respectively, while the optimal regimen was dominant (cost savings, reduced DALYs). In South Africa, maintaining current 6H coverage (0% of HHCs and 69% of PLHIV treated) would be associated with 3.6 (95% UR 3.0–4.3) million TB cases, 843,000 (598,000–1,201,000) deaths, and 36.7 (19.5–58.0) million DALYs and would cost $2.5 ($1.8–$3.6) billion. Expanding coverage with the 6H, minimal, or optimal regimen would reduce DALYs by 6.9% (95% UR 4.3%–95%), 15.5% (11.8%–18.9%), and 38.0% (32.7%–43.0%), respectively, with additional costs of $79 (−$7, $151) million and $40 (−$52, $140) million and savings of $608 ($443–$832) million, respectively. Compared to the status quo, estimated costs per DALY averted were $31 and $7 for scaling up the 6H and minimal regimens, while the optimal regimen was dominant. Study limitations included the focus on 2 countries, and no explicit consideration of costs incurred before the decision to prescribe TPT.ConclusionsOur findings suggest that scale-up of TPT regimens meeting minimum or optimal requirements would likely have important impacts on TB-associated outcomes and would likely be cost-effective or cost saving.

Placide Nsengiyumva and colleagues analyze costs and cost-effectiveness of scaling up target regimens for Tuberculosis Preventive Treatment among persons living with HIV and household contacts of TB patients in Brazil and South Africa.