Modelling the cost-effectiveness of mass screening and treatment for reducing Plasmodium falciparum malaria burden

Background

Past experience and modelling suggest that, in most cases, mass treatment strategies are not likely to succeed in interrupting Plasmodium falciparum malaria transmission. However, this does not preclude their use to reduce disease burden. Mass screening and treatment (MSAT) is preferred to mass drug administration (MDA), as the latter involves massive over-use of drugs. This paper reports simulations of the incremental cost-effectiveness of well-conducted MSAT campaigns as a strategy for P. falciparum malaria disease-burden reduction in settings with varying receptivity (ability of the combined vector population in a setting to transmit disease) and access to case management.

Methods

MSAT incremental cost-effectiveness ratios (ICERs) were estimated in different sub-Saharan African settings using simulation models of the dynamics of malaria and a literature-based MSAT cost estimate. Imported infections were simulated at a rate of two per 1,000 population per annum. These estimates were compared to the ICERs of scaling up case management or insecticide-treated net (ITN) coverage in each baseline health system, in the absence of MSAT.

Results

MSAT averted most episodes, and resulted in the lowest ICERs, in settings with a moderate level of disease burden. At a low pre-intervention entomological inoculation rate (EIR) of two infectious bites per adult per annum (IBPAPA) MSAT was never more cost-effective than scaling up ITNs or case management coverage. However, at pre-intervention entomological inoculation rates (EIRs) of 20 and 50 IBPAPA and ITN coverage levels of 40 or 60%, respectively, the ICER of MSAT was similar to that of scaling up ITN coverage further.

Conclusions

In all the transmission settings considered, achieving a minimal level of ITN coverage is a “best buy”. At low transmission, MSAT probably is not worth considering. Instead, MSAT may be suitable at medium to high levels of transmission and at moderate ITN coverage. If undertaken as a burden-reducing intervention, MSAT should be continued indefinitely and should complement, not replace, case management and vector control interventions.     

Combined Effects of the North Atlantic Oscillation and the Arctic Oscillation on Sea Surface Temperature in the Alborán Sea

We explored the possible effects of the North Atlantic Oscillation (NAO) and Arctic Oscillation (AO) on interannual sea surface temperature (SST) variations in the Alborán Sea, both separately and combined. The probability of observing mean annual SST values higher than average was related to NAO and AO values of the previous year. The effect of NAO on SST was negative, while that of AO was positive. The pure effects of NAO and AO on SST are obscuring each other, due to the positive correlation between them. When decomposing SST, NAO and AO in seasonal values, we found that variation in mean annual SST and mean winter SST was significantly related to the mean autumn NAO of the previous year, while mean summer SST was related to mean autumn AO of the previous year. The one year delay in the effect of the NAO and AO on the SST could be partially related to the amount of accumulated snow, as we found a significant correlation between the total snow in the North Alborán watershed for a year with the annual average SST of the subsequent year. A positive AO implies a colder atmosphere in the Polar Regions, which could favour occasional cold waves over the Iberian Peninsula which, when coupled with precipitations favoured by a negative NAO, may result in snow precipitation. This snow may be accumulated in the high peaks and melt down in spring-summer of the following year, which consequently increases the runoff of freshwater to the sea, which in turn causes a diminution of sea surface salinity and density, and blocks the local upwelling of colder water, resulting in a higher SST.     

Exploratory Analysis of Methods for Automated Classification of Laboratory Test Orders into Syndromic Groups in Veterinary Medicine

Background

Recent focus on earlier detection of pathogen introduction in human and animal populations has led to the development of surveillance systems based on automated monitoring of health data. Real- or near real-time monitoring of pre-diagnostic data requires automated classification of records into syndromes–syndromic surveillance–using algorithms that incorporate medical knowledge in a reliable and efficient way, while remaining comprehensible to end users.

Methods

This paper describes the application of two of machine learning (Naïve Bayes and Decision Trees) and rule-based methods to extract syndromic information from laboratory test requests submitted to a veterinary diagnostic laboratory.

Results

High performance (F₁-macro = 0.9995) was achieved through the use of a rule-based syndrome classifier, based on rule induction followed by manual modification during the construction phase, which also resulted in clear interpretability of the resulting classification process. An unmodified rule induction algorithm achieved an F_1-micro score of 0.979 though this fell to 0.677 when performance for individual classes was averaged in an unweighted manner (F_1-macro), due to the fact that the algorithm failed to learn 3 of the 16 classes from the training set. Decision Trees showed equal interpretability to the rule-based approaches, but achieved an F_1-micro score of 0.923 (falling to 0.311 when classes are given equal weight). A Naïve Bayes classifier learned all classes and achieved high performance (F_1-micro = 0.994 and F_1-macro = .955), however the classification process is not transparent to the domain experts.

Conclusion

The use of a manually customised rule set allowed for the development of a system for classification of laboratory tests into syndromic groups with very high performance, and high interpretability by the domain experts. Further research is required to develop internal validation rules in order to establish automated methods to update model rules without user input.     

Updating Known Distribution Models for Forecasting Climate Change Impact on Endangered Species

To plan endangered species conservation and to design adequate management programmes, it is necessary to predict their distributional response to climate change, especially under the current situation of rapid change. However, these predictions are customarily done by relating de novo the distribution of the species with climatic conditions with no regard of previously available knowledge about the factors affecting the species distribution. We propose to take advantage of known species distribution models, but proceeding to update them with the variables yielded by climatic models before projecting them to the future. To exemplify our proposal, the availability of suitable habitat across Spain for the endangered Bonelli''s Eagle (Aquila fasciata) was modelled by updating a pre-existing model based on current climate and topography to a combination of different general circulation models and Special Report on Emissions Scenarios. Our results suggested that the main threat for this endangered species would not be climate change, since all forecasting models show that its distribution will be maintained and increased in mainland Spain for all the XXI century. We remark on the importance of linking conservation biology with distribution modelling by updating existing models, frequently available for endangered species, considering all the known factors conditioning the species'' distribution, instead of building new models that are based on climate change variables only.     

Effects of ischemia-reperfusion on the absorption and esterase metabolism of diltiazem in rat intestine

Intestinal ischemia-reperfusion (I/R) is a serious clinical condition that triggers a complex inflammatory response. Inflammatory processes affect some enzymatic systems related to intestinal drug metabolism and bioavailability. Diltiazem (DTZ) is a calcium channel blocker, which is extensively metabolised in the intestine by esterases and different CYP450 isoforms. The main biotransformation pathway of DTZ in rats is desacetylation by esterases. This study analysed the effect of I/R on intestinal absorption and metabolism of DTZ, focusing on esterase activity, through different methodologies, after 60 min of superior mesenteric artery occlusion and 30 min of reperfusion or sham surgical procedures. The rate of DTZ appearance in blood during in situ studies increased significantly in the I/R group (0.094+/-0.014 10(-5) cm/s vs 0.271+/-0.110 10(-5) cm/s) and the calculated metabolised fraction of DTZ decreased significantly, showing an important reduction in the desacetylase activity in the I/R group. These results were supported by microsomal incubations, where desacetylase activity was related to esterases by specific inhibition, using paraoxon and bis-nitrophenylphosphate, and also by studies in everted rings. DTZ metabolism was higher in the jejunum than in the ileum, the esterase activity being affected by I/R in both regions. The present findings suggest that I/R injury clearly affects the esterases' activity and modifies the amount of DTZ and its metabolites in blood during in situ perfusion. This modification of intestinal esterase activity could be important for the pharmacokinetic behaviour of other drugs and prodrugs after intestinal pathologies involving inflammation and oxidative stress.     

Lotus tenuis tolerates the interactive effects of salinity and waterlogging by 'excluding' Na+ and Cl- from the xylem

Salinity and waterlogging interact to reduce growth of poorly adapted species by, amongst other processes, increasing the rate of Na(+) and Cl(-) transport to shoots. Xylem concentrations of these ions were measured in sap collected using xylem-feeding spittlebugs (Philaenus spumarius) from Lotus tenuis and Lotus corniculatus in saline (NaCl) and anoxic (stagnant) treatments. In aerated NaCl solution (200 mM), L. corniculatus had 50% higher Cl(-) concentrations in the xylem and shoot compared with L. tenuis, whereas concentrations of Na(+) and K(+) did not differ between the species. In stagnant-plus-NaCl solution, xylem Cl(-) and Na(+) concentrations of L. corniculatus increased to twice those of L. tenuis. These differences in xylem ion concentrations, which were not caused by variation in transpiration between the two species, contributed to lower net accumulation of Na(+) and Cl(-) in shoots of L. tenuis, indicating that ion transport mechanisms in roots of L. tenuis were contributing to better 'exclusion' of Cl(-) and Na(+) from shoots, compared with L. corniculatus. Root porosity was also higher in L. tenuis, due to constitutive aerenchyma, than in L. corniculatus, suggesting that enhanced root aeration contributed to the maintenance of Na(+) and Cl(-) 'exclusion' in L. tenuis exposed to stagnant-plus-NaCl treatment. Lotus tenuis also had greater dry mass than L. corniculatus after 56 d in NaCl or stagnant-plus-NaCl treatment. Thus, Cl(-) 'exclusion' is a key trait contributing to salt tolerance of L. tenuis, and 'exclusion' of both Cl(-) and Na(+) from the xylem enables L. tenuis to tolerate, better than L. corniculatus, the interactive stresses of salinity and waterlogging.     

HLA class I expression in metastatic melanoma correlates with tumor development during autologous vaccination

Our knowledge of the mechanisms underlying tumor-specific immune response and tumor escape has considerably increased. HLA class I antigen defects remain an important tumor escape mechanism since they influence the interactions between tumor cells and specific T and NK cells in the course of malignant disease. We have studied here HLA class I expression in six subcutaneous metastases obtained from a melanoma patient immunized with an autologous melanoma cell vaccine (M-VAX). We report in this paper that HLA class I antigen expression on these metastatic lesions strongly correlated with the course of the disease. The three metastases that were partially regressing at the time of their excision showed a strong HLA class I expression, whereas the progressing ones showed a very weak or negative staining with most of the anti-HLA class I mAbs used. Real-time quantitative PCR of the samples obtained from microdissected tumor tissue revealed a significant difference in the mRNA levels of HLA-ABC heavy chain and beta2m between the two types of metastases, i.e., lower levels in progressing metastases and high levels in regressing ones, confirming the immunohistological findings. This is, to our knowledge, the first report where the clinical outcome of different HLA class I positive and negative melanoma metastases can be clearly correlated with the regression and progression of the disease, respectively.     

Binding of Cyt1Aa and Cry11Aa toxins of Bacillus thuringiensis serovar israelensis to brush border membrane vesicles of Tipula paludosa (Diptera: Nematocera) and subsequent pore formation

Bacillus thuringiensis serovar israelensis (B. thuringiensis subsp. israelensis) produces four insecticidal crystal proteins (ICPs) (Cry4A, Cry4B, Cry11A, and Cyt1A). Toxicity of recombinant B. thuringiensis subsp. israelensis strains expressing only one of the toxins was determined with first instars of Tipula paludosa (Diptera: Nematocera). Cyt1A was the most toxic protein, whereas Cry4A, Cry4B, and Cry11A were virtually nontoxic. Synergistic effects were recorded when Cry4A and/or Cry4B was combined with Cyt1A but not with Cry11A. The binding and pore formation are key steps in the mode of action of B. thuringiensis subsp. israelensis ICPs. Binding and pore-forming activity of Cry11Aa, which is the most toxic protein against mosquitoes, and Cyt1Aa to brush border membrane vesicles (BBMVs) of T. paludosa were analyzed. Solubilization of Cry11Aa resulted in two fragments, with apparent molecular masses of 32 and 36 kDa. No binding of the 36-kDa fragment to T. paludosa BBMVs was detected, whereas the 32-kDa fragment bound to T. paludosa BBMVs. Only a partial reduction of binding of this fragment was observed in competition experiments, indicating a low specificity of the binding. In contrast to results for mosquitoes, the Cyt1Aa protein bound specifically to the BBMVs of T. paludosa, suggesting an insecticidal mechanism based on a receptor-mediated action, as described for Cry proteins. Cry11Aa and Cyt1Aa toxins were both able to produce pores in T. paludosa BBMVs. Protease treatment with trypsin and proteinase K, previously reported to activate Cry11Aa and Cyt1Aa toxins, respectively, had the opposite effect. A higher efficiency in pore formation was observed when Cyt1A was proteinase K treated, while the activity of trypsin-treated Cry11Aa was reduced. Results on binding and pore formation are consistent with results on ICP toxicity and synergistic effect with Cyt1Aa in T. paludosa.     

The Association of Income with Health Behavior Change and Disease Monitoring among Patients with Chronic Disease

Background

Management of chronic diseases requires patients to adhere to recommended health behavior change and complete tests for monitoring. While studies have shown an association between low income and lack of adherence, the reasons why people with low income may be less likely to adhere are unclear. We sought to determine the association between household income and receipt of health behavior change advice, adherence to advice, receipt of recommended monitoring tests, and self-reported reasons for non-adherence/non-receipt.

Methods

We conducted a population-weighted survey, with 1849 respondents with cardiovascular-related chronic diseases (heart disease, hypertension, diabetes, stroke) from Western Canada (n = 1849). We used log-binomial regression to examine the association between household income and the outcome variables of interest: receipt of advice for and adherence to health behavior change (sodium reduction, dietary improvement, increased physical activity, smoking cessation, weight loss), reasons for non-adherence, receipt of recommended monitoring tests (cholesterol, blood glucose, blood pressure), and reasons for non-receipt of tests.

Results

Behavior change advice was received equally by both low and high income respondents. Low income respondents were more likely than those with high income to not adhere to recommendations regarding smoking cessation (adjusted prevalence rate ratio (PRR): 1.55, 95%CI: 1.09–2.20), and more likely to not receive measurements of blood cholesterol (PRR: 1.72, 95%CI 1.24–2.40) or glucose (PRR: 1.80, 95%CI: 1.26–2.58). Those with low income were less likely to state that non-adherence/non-receipt was due to personal choice, and more likely to state that it was due to an extrinsic factor, such as cost or lack of accessibility.

Conclusions

There are important income-related differences in the patterns of health behavior change and disease monitoring, as well as reasons for non-adherence or non-receipt. Among those with low income, adherence to health behavior change and monitoring may be improved by addressing modifiable barriers such as cost and access.