Travel Medicine and Infectious Disease

BackgroundDengue is a major public health challenge and a growing problem due to climate change. The release of Aedes aegypti mosquitoes infected with the intracellular bacterium Wolbachia is a novel form of vector control against dengue. However, there remains a need to evaluate the benefits of such an intervention at a large scale. In this paper, we evaluate the potential economic impact and cost-effectiveness of scaled Wolbachia deployments as a form of dengue control in Vietnam - targeted at the highest burden urban areas. MethodsTen settings within Vietnam were identified as priority locations for potential future Wolbachia deployments (using a population replacement strategy). The effectiveness of Wolbachia deployments in reducing the incidence of symptomatic dengue cases was assumed to be 75%. We assumed that the intervention would maintain this effectiveness for at least 20 years (but tested this assumption in the sensitivity analysis). A cost-utility analysis and cost-benefit analysis were conducted. ResultsFrom the health sector perspective, the Wolbachia intervention was projected to cost US$420 per disability-adjusted life year (DALY) averted. From the societal perspective, the overall cost-effectiveness ratio was negative, i.e. the economic benefits outweighed the costs. These results are contingent on the long-term effectiveness of Wolbachia releases being sustained for 20 years. However, the intervention was still classed as cost-effective across the majority of the settings when assuming only 10 years of benefits. ConclusionOverall, we found that targeting high burden cities with Wolbachia deployments would be a cost-effective intervention in Vietnam and generate notable broader benefits besides health gains.

Abstract of the StudyO_ST_ABSBackgroundC_ST_ABSChronic Hepatitis B infection comprises the mortality among viral hepatitis despite primary hepatitis B vaccination was implemented in different states health programs. Different modalities of combining active and passive hepatitis B vaccination were conducted. Pregnant women hepatitis screening was not yet streamlined in the clinical management due to social and economic challenges. Fetal to maternal vertical transmission of hepatitis B virus is still a burden to our health system. It is the objective of the study to present the cost of incorporating hepatitis B immunoglobulin vaccine in the current vaccination program, as strengthen the preventive measures of hepatitis infection locally and nationally. MethodsSurvey questionnaires were utilized to gather demographic data among randomly selected pregnant women during their prenatal visits at the hospital. Hospital and city-based census were used for projecting cost and revenues of having hepatitis B immunoglobulin vaccination. ResultsA total of 74 respondents were identified. A financial 5-year was forecast would show a revenue of Php 1,494,500.00 ($28,869.5) on the 5th year and would spare the mothers from OOP expenses with a total amount of Php 945,500 ($18,264.40). Moreover, the monthly revenue of Hep B Ig vaccination (based on 2016 census) on a city-wide was forecasted. The difference of the total amount of PHIC reimbursement from the amount of vaccine purchasing would give the facility a projected revenue of Php 3,381,123.00 ($65,313.62) or a monthly average of Php (281,760.25). A total of 1,380 newborns would be at risk to hepatitis B-reactive mothers and would be protected by securing hepatitis B immunoglobulin and be made available in the hospital pharmacy. Furthermore, pregnant women are protected against financial risk of unnecessary out-of-pocket expenses. ConclusionThis study found that the pregnant women was aware of the economic burden of hepatitis B immunoglobulin vaccine and it would benefit the healthcare facility by strategically addressing the external factors for a sustained vaccination program.

China experienced a major nationwide wave of SARS-CoV-2 infections in December 2022, immediately after lifting strict interventions, despite the majority of the population having already received inactivated COVID-19 vaccines. Due to the rapid waning of protection and the emergence of Omicron XBB.1.5, the risk of another COVID-19 wave remains high. It is still unclear whether the health care system will be able to manage the demand during this potential XBB.1.5 wave and if the number of associated deaths can be reduced to a level comparable to that of seasonal influenza. Thus, we developed a mathematical model of XBB.1.5 transmission using Shanghai as a case study. We found that a potential XBB.1.5 wave is less likely to overwhelm the health care system and would result in a death toll comparable to that of seasonal influenza, albeit still larger, especially among elderly individuals. Our analyses show that a combination of vaccines and antiviral drugs can effectively mitigate an XBB.1.5 epidemic, with a projected number of deaths of 2.08 per 10,000 individuals. This figure corresponds to a 70-80% decrease compared to the previous Omicron wave and is comparable to the level of seasonal influenza. The peak prevalence of hospital admissions and ICU admissions are projected at 28.89 and 2.28 per 10,000 individuals, respectively, suggesting the need for a moderate increase in the capacity of the health care system. Our findings emphasize the importance of improving vaccination coverage, particularly among the older population, and the use of antiviral treatments.

In early 2020, South Korea experienced a large coronavirus disease 2019 (COVID-19) outbreak. However, despite its proximity to China, where the virus had emerged, and the high population density of the Seoul metropolitan area, a major international hub, South Korea effectively contained the spread of COVID-19 using non-pharmaceutical interventions until vaccine distribution in 2021. Here, we built a metapopulation model with a susceptible-exposed-infectious-quarantined-recovered (SEIQR) structure and combined it with the ensemble adjustment Kalman filter to infer the transmission dynamics of COVID-19 in South Korea from February 2020 until vaccine deployment. Over the study period, the fraction of documented infections (ascertainment rate) was found to increase from 0.50 (95% credible interval (CI): 0.26--0.77) to 0.62 (95% CI: 0.39--0.86). The cumulative number of total infections, including both documented cases and undocumented infections, was less than 1% of the South Korean population at the end of the simulation period, indicating that the majority of people had yet to be infected when vaccine administration began. These findings enhance understanding of the COVID-19 outbreak in South Korea and highlight the importance of preparedness and response in managing global pandemics.

IntroductionThe adoption of biologic therapies imposes a substantial financial burden on the Jordanian healthcare system. Ranibizumab is prescribed for various retinal disorders, and its associated costs are considerable. The introduction of biosimilars is beneficial in retaining desired clinical parameters while providing cost relief and enhanced access to patients. ObjectiveTo examine the budget impact and expanded access of switching to ranibizumabs biosimilar for the management of retinal diseases in guideline-based practice and in real-world practice in Jordan. MethodA 4-year budget impact analysis from Jordanian public sector payers sector was performed (2023 to 2026) that included patient prevalence and incidence, average ranibizumab dose per year, and anticipated shifts in the market share of ranibizumab and aflibercept. The model took into account the anticipated price erosion of the biosimilar in 2025 and 2026. Sensitivity analyses were performed to assess the effect of changes in uptake rates, price, and market share. ResultsThe annual cost savings per patient when switching from aflibercept to ranibizumabs biosimilar were from 20.55 JOD (Jordanian Dinar) to 1519.93 JOD, translating to a percentage saving of 2.68% to 35.12% across the various scenarios and indications. The total budget impact ranged widely from 6.9 M JOD to 21.2 M JOD based on treatment regimens adjusted to current practice, PRN (Pro re nata), or T&E (Treat and extend). Patient access improved between 2.75% to 124.76% in the different scenarios. ConclusionThe introduction of ranibizumabs biosimilar significantly reduces the expenditures and enhances treatment access.

BackgroundA novel coronavirus (2019-nCoV) emerged in Wuhan City, China, at the end of 2019 and has caused an outbreak of human-to-human transmission with a Public Health Emergency of International Concern declared by the World Health Organization on January 30, 2020. AimWe aimed to estimate the potential risk and geographic range of Wuhan novel coronavirus (2019-nCoV) spread within and beyond China from January through to April, 2020. MethodsA series of domestic and international travel network-based connectivity and risk analyses were performed, by using de-identified and aggregated mobile phone data, air passenger itinerary data, and case reports. ResultsThe cordon sanitaire of Wuhan is likely to have occurred during the latter stages of peak population numbers leaving the city before Lunar New Year (LNY), with travellers departing into neighbouring cities and other megacities in China. We estimated that 59,912 air passengers, of which 834 (95% UI: 478 - 1349) had 2019-nCoV infection, travelled from Wuhan to 382 cities outside of mainland China during the two weeks prior to Wuhans lockdown. The majority of these cities were in Asia, but major hubs in Europe, the US and Australia were also prominent, with strong correlation seen between predicted importation risks and reported cases. Because significant spread has already occurred, a large number of airline travellers (3.3 million under the scenario of 75% travel reduction from normal volumes) may be required to be screened at origin high-risk cities in China and destinations across the globe for the following three months of February to April, 2020 to effectively limit spread beyond its current extent. ConclusionFurther spread of 2019-nCoV within China and international exportation is likely to occur. All countries, especially vulnerable regions, should be prepared for efforts to contain the 2019-nCoV infection.

The 2022 mpox outbreak has spread rapidly across multiple countries in the non-endemic region, mainly among men who have sex with men (MSM), while China only has limited recorded importation and no local outbreak. We constructed probabilistic models to simulate the risk of mpox importation in mainland China, with the help of reported monkeypox cases during this multi-country outbreak and the international air-travel data. And we further evaluated the mpox outbreak potential given that undetected mpox infections were introduced into men who have sex with men, considering different transmissibility, population immunity and population activity. We found that the reduced international air-travel volume and stringent border entry policy decreased about 94% and 69% mpox importations respectively. Once a mpox case is introduced into active MSM population with almost no population immunity, the risk of triggering local transmission is estimated at 42%, and would rise to >95% with over six cases. Our study demonstrates the key role of the reduced international air-travel volume and stringent border entry policy during the COVID-19 pandemic on reducing mpox importations, and the subsequent risk of triggering local outbreaks among MSM.

Understanding changes in human mobility in the early stages of the COVID-19 pandemic is crucial for assessing the impacts of travel restrictions designed to reduce disease spread. Here, relying on data from mainland China, we investigated the spatio-temporal characteristics of human mobility between 1st January and 1st March 2020 and discussed their public health implications. An outbound travel surge from Wuhan before travel restrictions were implemented was also observed across China due to the Lunar New Year, indicating that holiday travel may have played a larger role in mobility changes compared to impending travel restrictions. Holiday travel also shifted healthcare pressure related to COVID-19 towards locations with lower access to care. Network analyses showed no sign of major changes in the transportation network after Lunar New Year. Changes observed were temporary and have not yet led to structural reorganisation of the transportation network at the time of this study. One sentence summaryUnderstanding travel before, during, and after the introduction of travel restrictions in China in response to the COVID-19 Pandemic.

BackgroundIn the Saudi Arabia, we estimated the cost-effectiveness between fecal DNA methylation test (FDMT) and fecal immunochemical testing (FIT) to detect colorectal cancer (CRC) and precancerous lesions in the national screening program. Participants and methodsA Markov model was used from 45 to 74 years old CRC screening to compare the cost-effectiveness with the FDMT vs FIT. We predicated the longitudinal participation patterns in the perfect adherence vs organized programs screening covered by national budgets. Outcomes incorporated the incidence rates and mortality rates, cost, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios (ICERs) under the perfect adherence as well as incidence and mortality forecast within 3, 6 and 9 years. ResultsUnder the perfect adherence, the total cost of FDMT was cheaper 38.16% than FIT and extends 0.22 QALYs per person. Furthermore, FDMT was more cost-effective as ICERs ($1487.30 vs $1982.42 per QALY saved) compared with FIT test. Therefore, FDMT test dominated than FIT every year (more costly and less effective). Compared with the organized FDMT programs (6.6% initial positive rate and 54% coloscopy compliance rate), the FIT program (5.8% initial positive rate and 48% coloscopy compliance rate) had 6.25 times to 7.76 times on the incidence rates; 5.12 times to 12.19 times on the mortality rates among 3, 6 and 9 years prediction. ConclusionsThrough the Markov model, we compared FDMT was less costly and more effective than the FIT test under the perfect and organized adherence within nine years prediction. It implied that FDMT might the novel cost-effective tool for Saudi Arabia national screening program.

Typhoid remains a preventable disease that primarily affects low- and middle-income countries. We conducted a scoping review to synthesize evidence on the epidemiological models and economic analyses of typhoid conjugate vaccine (TCV), focusing on the cost of illness of typhoid, the cost of vaccination, cost-effectiveness, and public health benefits of TCV. A search was conducted across PubMed, Web of Science, International Health Technology Assessment, Scopus, and the National Health Service Economic Evaluation Database, following Arksey and OMalleyss framework. Screening and data extraction were managed using Covidence and an Excel-based template. Extracted data included study design, population, outcomes, model parameters, and cost-effectiveness data, converted to 2024, United States Dollars (USD) for comparability. Findings were summarized by key outcomes. The economic burden of typhoid varied by region, care type, and demographics. Direct medical costs ranged from USD 1.3 to USD 1543, direct non-medical costs varied from USD 1.3 to USD 60.1, and indirect costs ranged from USD 14.1 to USD 794. Cost of vaccination per dose ranged from USD 2.80 - USD 5.40 (India), USD 0.87 - USD 1.01 (Malawi), and USD 2.99 (Zimbabwe), while the cost of delivering the vaccine ranged from USD 0.48- USD 0.99 (financial) and USD 1.11 - USD 1.87 (economic) per dose. Models predicted 2-94% case reductions and 0-100% mortality reductions. Economic evaluations reported ICERs of USD 124 to USD 53,773 per DALY averted and USD - 4,251 to USD 103,344 per QALY gained, with high-incidence settings often resulting in cost savings. Sensitive parameters were typhoid incidence rate, vaccine efficacy, and vaccination costs. TCV introduction is influenced by disease burden, vaccination costs, and health outcomes, which vary by region. Cost-effectiveness depends on incidence, perspective, and vaccine strategy, emphasizing the need for context-specific evaluations. Targeted strategies, particularly in high-incidence and urban areas, are often cost-effective and sometimes cost-saving.

The outbreak of the novel coronavirus disease, COVID-19, originating from Wuhan, China in early December, has infected more than 70,000 people in China and other countries and has caused more than 2,000 deaths. As the disease continues to spread, the biomedical society urgently began identifying effective approaches to prevent further outbreaks. Through rigorous epidemiological analysis, we characterized the fast transmission of COVID-19 with a basic reproductive number 5.6 and proved a sole zoonotic source to originate in Wuhan. No changes in transmission have been noted across generations. By evaluating different control strategies through predictive modeling and Monte carlo simulations, a comprehensive quarantine in hospitals and quarantine stations has been found to be the most effective approach. Government action to immediately enforce this quarantine is highly recommended.

BackgroundPakistan has a hepatitis C virus (HCV) infection prevalence of 6-9% and aims to achieve World Health Organization (WHO) targets for elimination of HCV by the year 2030 through scaling HCV diagnosis and accelerating access to care. The clinical and economic benefits of various HCV testing strategies have not yet been evaluated in Pakistan. ObjectiveTo evaluate the potential cost-effectiveness of a reference laboratory-based (CEN) confirmatory testing approach vs a molecular near-patient point-of-care (POC) confirmatory approach to screen the general population for HCV in Pakistan. MethodsWe developed a decision-analytic model comparing HCV testing under two scenarios: screening with an anti-HCV antibody test (Anti-HCV) followed by either POC nucleic acid testing (NAT) (Anti-HCV-POC), or reference laboratory NAT (Anti-HCV-CEN), using data from published literature, the Pakistan Ministry of Health, and expert judgment. Outcome measures included: number of HCV infections identified per year, percentage of individuals correctly classified, total costs, average costs per individual tested, and cost-effectiveness. Sensitivity analysis was also performed. ResultsAt a national level for a tested population of 25 million, the Anti-HCV-CEN strategy would identify 142,406 more HCV infections in one year and increase correct classification of individuals by 0.57% compared with the Anti-HCV-POC strategy. The total annual cost of HCV testing was reduced using the Anti-HCV-CEN strategy by $7.68 million ($0.31 per person). Thus, incrementally, the Anti-HCV-CEN strategy costs less and identifies more HCV infections than Anti-HCV-POC. ConclusionsAnti-HCV-CEN would provide the best value for money when scaling up HCV testing in Pakistan. Significance statementO_LIHepatitis C virus (HCV) infection constitutes a major medical and public health burden in Pakistan C_LIO_LIWidespread testing is important to identify those that are chronically infected in order to link them to treatment services C_LIO_LIThe optimal and most cost-effective testing approach to scale up HCV testing to support elimination efforts in Pakistan has not been established C_LIO_LIHigh throughput reference laboratory testing would provide the best value for money when scaling-up HCV testing in Pakistan C_LI

BackgroundThe coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread to nearly every country in the world since it first emerged in China in December 2019. Many countries have implemented social distancing as a measure to flatten the curve of the ongoing epidemics. Evaluation of the impact of government-imposed social distancing and of other measures to control further spread of COVID-19 is urgent, especially because of the large societal and economic impact of the former. The aim of this study was to compare the effectiveness of self-imposed prevention measures and of short-term government-imposed social distancing in mitigating, delaying, or preventing a COVID-19 epidemic. Methods and FindingsWe developed a deterministic compartmental transmission model of SARS-CoV-2 in a population stratified by disease status (susceptible, exposed, infectious with mild or severe disease, diagnosed and recovered) and disease awareness status (aware and unaware) due to the spread of COVID-19. Self-imposed measures were assumed to be taken by disease-aware individuals and included handwashing, mask-wearing, and social distancing. Government-imposed social distancing reduced the contact rate of individuals irrespective of their disease or awareness status. The model was parameterized using current best estimates of key epidemiological parameters from COVID-19 clinical studies. The model outcomes included the peak number of diagnoses, attack rate, and time until the peak number of diagnoses. For fast awareness spread in the population, selfimposed measures can significantly reduce the attack rate, diminish and postpone the peak number of diagnoses. A large epidemic can be prevented if the efficacy of these measures exceeds 50%. For slow awareness spread, self-imposed measures reduce the peak number of diagnoses and attack rate but do not affect the timing of the peak. Early implementation of short-term government-imposed social distancing can only delay the peak (by at most 7 months for a 3-month intervention). The delay can be even longer and the height of the peak can be additionally reduced if this intervention is combined with self-imposed measures that are continued after government-imposed social distancing has been lifted. Our analyses do not account for stochasticity, demographics, heterogeneities in contact patterns or mixing, spatial effects, imperfect isolation of individuals with severe disease, and reinfection with COVID-19. ConclusionsOur results suggest that information dissemination about COVID-19, which causes individual adaption of handwashing, mask-wearing and social distancing can be an effective strategy to mitigate and delay the epidemic. Early-initiated short-term government-imposed social distancing can buy time for healthcare systems to prepare for an increasing COVID-19 burden. We stress the importance of disease awareness in controlling the ongoing epidemic and recommend that, in addition to policies on social distancing, governments and public health institutions mobilize people to adopt self-imposed measures with proven efficacy in order to successfully tackle COVID-19. Author summaryO_ST_ABSWhy was this study done?C_ST_ABSO_LIAs of May 2020, the coronavirus disease (COVID-19) caused by the novel coronavirus (SARS-CoV-2) has spread to nearly every country in the world since it first emerged in China in December 2019. C_LIO_LIConfronted with a COVID-19 epidemic, public health policymakers in different countries are seeking recommendations on how to delay and/or flatten its peak. C_LIO_LIEvaluation of the impact of social distancing mandated by the governments in many countries and of other prevention measures to control further spread of COVID-19 is urgent, especially because of the large societal and economic impact of the former. C_LI What did the researchers do and find?O_LIWe developed a transmission model to evaluate the impact of self-imposed measures (handwashing, mask-wearing, and social distancing) due to awareness of COVID-19 and of short-term government-imposed social distancing on the epidemic dynamics. C_LIO_LIWe showed that self-imposed measures can prevent a large epidemic if their efficacy exceeds 50%. C_LIO_LIShort-term government-imposed social distancing that is initiated early into the epidemic can buy time (at most 7 months for a 3-month intervention) for healthcare systems to prepare for an increasing COVID-19 burden. C_LIO_LIThe delay to the peak number of diagnoses can be even longer and the height of the peak can be additionally reduced if the same intervention is combined with self-imposed measures that are continued after lifting government-imposed social distancing. C_LI What do these findings mean?O_LIRaising awareness of self-imposed measures such as handwashing and mask-wearing is crucial in controlling the ongoing epidemic. C_LIO_LIShort-term early-initiated government-imposed social distancing combined with self-imposed measures provides essential time for increasing capacity of healthcare systems and can significantly mitigate the epidemic. C_LIO_LIIn addition to policies on social distancing, governments and public health institutions should continuously mobilize people to adopt self-imposed measures with proven efficacy in order to successfully tackle COVID-19. C_LI

BackgroundThe Gonococcal Isolate Surveillance Project (GISP) is a sentinel surveillance system to monitor the spread of antimicrobial-resistant (AMR) gonorrhea. Under GISP surveillance strategy, urethral isolates are utilized for monitoring the spread of the resistance and the obtained estimates are used for informing the gonorrhea treatment guidelines. In 2017, the enhanced Gonococcal Isolate Surveillance Project (eGISP) was established which also includes the non-urethral isolates. Using eGISP estimates for informing the gonorrhea treatment guidelines is an alternative surveillance strategy that can be used. MethodsWe utilized our previously developed continuous-time agent-based model of gonorrhea transmission among the US men who have sex with men (MSM) population and calculated the total number of discounted quality-adjusted life years (QALYs) and total discounted costs over 25 years under GISP and eGISP surveillance strategy. We also evaluated cost-effectiveness of both surveillance strategies. ResultsUnder GISP surveillance strategy, $2.9M (95% uncertainty interval: $23,131, $9.4M) were saved and 31.3 (0, 134.9) QALYs were gained in the simulated cohort of 10,000 US MSM over 25 years compared to no surveillance. Performing eGISP surveillance strategy instead would result in additional $57,449 (-$100,914, $221,663) saved and 0.59 (-0.79, 2.5) QALYs gained. ConclusionThe current GISP surveillance strategy significantly reduces the costs and increases the health benefits compared to no surveillance. However, switching from the current strategy to eGISP strategy is cost saving and should be considered in order to improve the population health and reduce the financial burden of gonorrhea.

The study sought to investigate how the number of confirmed cases of COVID-19 have evolved in the most recent three months across the world, and what insights the trends may provide about the second half of the pandemics first year using a situation analysis approach based on national income, temperature, trade intensity with China, and location defined by longitude and latitude. The study confirmed the negative relationship between COVID-19 cases and temperature. It contributed to the resolution of the conflicting results about latitude after organizing it into a categorical variable instead of its continuous form. This approach works because the average temperature in the 15{degrees}S to 15{degrees}N region remains similar to the average temperatures in both the Above 15{degrees}N region and the Below 15{degrees}S region during their summer months because the 15{degrees}S to 15{degrees}N region does not experience the marked seasonal changes in temperature. Given the negative association between temperature and case numbers, this suggests that countries in the 15{degrees}S to 15{degrees}N region might continue exhibiting the low numbers they have thus far exhibited through the second half of this year, even as numbers climb in the Below 15{degrees}S region. To succeed, their policymakers must control importation of the disease by implementing effective testing, quarantining, and contact tracing for people entering their borders. Policymakers in countries Below 15{degrees}S region may manage their inherent risks by applying lessons learned from countries in the Above 15{degrees}N region during these past months. Such preventative measures may allow the world to avoid the drastic lockdown policies and facilitate rapid global economic recovery from this pandemic.

IntroductionThe study aims to estimate out-of-pocket household expenditures associated with the diagnosis and follow-up treatment of Congenital Zika Syndrome (CZS) in children affected during the 2015-2016 epidemic in Brazil. MethodsNinety-six interviews were held in the cities of Fortaleza and Rio de Janeiro in a convenience sample, using a questionnaire on sociodemographic characteristics and private household expenditures associated with the syndrome, which also allowed estimating catastrophic expenditures resulting from care for CZS. ResultsMost of the mothers interviewed in the study were brown, under 34 years of age, unemployed, and reported a monthly family income of two minimum wages or less. Spending on medicines accounted for 77.6% of the out-of-pocket medical expenditures, while transportation and food were the main components of nonmedical expenditures, accounting for 79% of this total. The mean annual out-of-pocket expenditures by households was equivalent to almost a quarter of the annual minimum wage. ConclusionsThe affected households were largely low-income and suffered catastrophic expenditures due to the disease. Public policies should consider the financial and healthcare needs of these families to ensure adequate support for individuals affected by CZS.

BackgroundEpidemiological figures of Covid-19 epidemic in Italy are worse than those observed in China. MethodsWe modeled the Covid-19 outbreak in Italian Regions vs. Lombardy to assess the epidemics progression and predict peaks of new daily infections and total cases by learning from the entire Chinese epidemiological dynamics. We trained an artificial neural network model, a modified auto-encoder with Covid-19 Chinese data, to forecast epidemic curve of the different Italian regions, and use the susceptible-exposed-infected-removed (SEIR) compartment model to predict the spreading and peaks. We have estimated the basic reproduction number (R0) - which represents the average number of people that can be infected by a person who has already acquired the infection - both by fitting the exponential growth rate of the infection across a 1-month period, and also by using a day by day assessment, based on single observations. ResultsThe expected peak of SEIR model for new daily cases was at the end of March at national level. The peak of overall positive cases is expected by April 11th in Southern Italian Regions, a couple of days after that of Lombardy and Northern regions. According to our model, total confirmed cases in all Italy regions could reach 160,000 cases by April 30th and stabilize at a plateau. ConclusionsTraining neural networks on Chinese data and use the knowledge to forecast Italian spreading of Covid-19 has resulted in a good fit, measured with the mean average precision between official Italian data and the forecast.

To evaluate the cost effectiveness of six disease modifying anti-rheumatic drug (DMARD) treat-to-target treatment strategies for patients with rheumatoid arthritis in Zanzibar. A Markov model was used to calculate the cost-effectiveness of various DMARD strategies in the treatment of rheumatoid arthritis over a three-year period. A health-provider perspective was used and only outpatient costs were considered. The Clinical Disease Activity Index (CDAI) was utilized for measurement of efficacy and values were obtained from literature. Quality Adjusted Life Years (QALYs) were obtained from 122 patients attending the rheumatology clinic at Mnazi Mmoja Hospital. Data on costs were obtained from the central medical stores and hospital administration. Treatment strategies were given in sequential approach based on treat to target goals of therapy. This included methotrexate monotherapy, methotrexate + sulfasalazine + hydroxychloroquine, methotrexate followed by one or two biologic/targeted-synthetic DMARDs (b/tsDMARDs). Probabilistic and one way sensitivity analysis were performed. Scenario analysis was undertaken comparing drug prices from India and Scandinavia. Costs of therapy/patient/three years ranged from USD 634 for methotrexate monotherapy and USD 5011 for methotrexate and two consecutive b/tsDMARDs. The highest and lowest effects were 2.209 and 2.079 QALYs gained from methotrexate therapy + two consecutive b/tsDMARDs and methotrexate monotherapy, respectively. From a healthcare perspective methotrexate monotherapy was the cost-effective option at a willingness to pay of USD 282. Pairwise comparison also favored methotrexate monotherapy as the feasible option. We found that increasing the willingness to pay led to a change in the most acceptable option from methotrexate monotherapy to methotrexate followed by b/tsDMARD. Methotrexate monotherapy is the cost-effective option for the management of rheumatoid arthritis in Zanzibar. Other options may be feasible if the willingness to pay threshold is increased or the drug prices are lowered, particularly for the b/tsDMARDs.

BackgroundA novel coronavirus (SARS-CoV-2) spread from the capital of the Hubei province in China to the rest of the country, then to most of the world. To anticipate future trends in the development of the epidemic, we explore here, based on public records of infected persons how variation in the virus tropism could end up in different patterns, warranting specific way to handle the epidemic. MethodsWe use a compartmental model to describe the evolution of an individual through several possible states: susceptible, infected, alternative infection, detected and removed. We fit the parameters of the model to the existing data taking into account significant quarantine changes where necessary. ResultsThe model indicates that Wuhan quarantine measures were effective but that alternative virus forms and a second propagation route are compatible with available data. For Singapore and Shenzhen region the secondary route does not seem to be active yet and the epidemic size limited. ConclusionsThe alternative infection tropism (the gut tropism) and a secondary propagation route are validated hypotheses using a model fitted by the available data. Corresponding prevention measures that take into account both routes should be implemented to the benefit of epidemic control.

BackgroundThe COVID-19 outbreak on the Diamond Princess (DP) cruise ship provided empirical data to study the transmission potential of COVID-19 under quarantine with the presence of asymptomatic cases. MethodsWe studied the changes in R0 on the DP from January 21 to February 19, 2020 based on chain-binomial models under two scenarios: no quarantine assuming a random mixing condition, and quarantine of passengers in cabins -- passengers may get infected either by an infectious case in a shared cabin or by asymptomatic crew who continued to work. ResultsEstimates of R0 at the beginning of the epidemic were 3.27 (95% CI, 3.02-3.54) and 3.78 (95% CI, 3.49-4.09) respectively for serial intervals of 5 and 6 days; and when quarantine started, with the reported asymptomatic ratio 0.505, R0 rose to 4.18 (95%CI, 3.86-4.52) and 4.73 (95%CI, 4.37-5.12) respectively for passengers who might be exposed to the virus due to contacts with asymptomatic crew. The overall R0 for both crew and passengers was decreased to 2.55 (95%CI, 2.36-2.76) and 2.90 (95% CI, 2.67-3.13). Results show that the higher the asymptomatic ratio is, the more infectious contacts would happen. ConclusionsWe find evidence to support a US CDC report that "a high proportion of asymptomatic infections could partially explain the high attack rate among cruise ship passengers and crew." Our study suggests that the effects of quarantine may be limited if the asymptomatic ratio is high, implying that a combination of preventive measures is needed to stop the spread of virus.