Analysis of the Full Economic Cost for Japanese Encephalitis Under Different Risk Scenarios for Business Travelers to Asia.

OBJECTIVE: Methods for assessing the costs and benefits of administering vaccines to international business/occupational travelers, assignees, and expatriates have neglected the impact of health and treatment on work productivity. The research objective is to evaluate the benefit to cost ratio of the Japanese encephalitis (JE) vaccine for international business/occupational travelers to Asia and other endemic areas incorporating a health and productivity approach. METHODS: Costs and benefits were estimated using actuarial methods with data obtained from secondary sources describing prevalence of infection risk and health outcomes, and business traveler demographic and travel characteristics. Results assumed 2018 salaries and prices, with employee time valued according to total compensation. RESULTS: Risks contracting JE vary widely on the basis of length of trip, season, and destination. The productivity benefits of vaccinating a traveler outweigh the vaccination costs for those staying 30 days or longer in endemic areas during one or more transmission seasons ($2009 vs $750 per traveler), and for business travelers to endemic areas during the transmission season with outdoor activities for the average 2-week/15.4-day international business trip ($502 to $815 vs $500). Vaccination costs outweigh the productivity benefits for short-term travelers who remain in urban areas or travel outside of the transmission season ($10 vs $500). CONCLUSION: JE Vaccination for business travelers in the active transmission season has a net benefit under certain conditions that are not commonly considered risky, such as average-length trips to peri-urban areas, in situations where contracting disease would result in significant business disruption, or when multiple trips are anticipated over several years.

The changing epidemiology of Japanese encephalitis and New data: the implications for New recommendations for Japanese encephalitis vaccine.

The epidemiology of Japanese Encephalitis and risk to the traveler has changed and continues to evolve. The spread of Japanese Encephalitis virus into new environments, changes in agricultural practice and animal vectors, climate change, peri-urban growth, changes in international travel to Asia, personal risk factors, mosquito vector free transmission, interactions with other flaviviruses and better information on infections without encephalitis and other factors make Japanese Encephalitis an underappreciated risk. There has also been a change in the incidence of Japanese Encephalitis cases that questions the current travel duration and geographic based recommendations. A safe, effective vaccine (Ixiaro) that may be administered in a short course regimen is now available in the United States without the risks of the previous vaccine. However, the vaccine is significantly underutilized. These changes in the epidemiology and new data on the risks of the Japanese Encephalitis virus require a review of the practice guidelines and expert recommendations that do not reflect the current state of knowledge.

An Update on Travel Vaccines and Issues in Travel and International Medicine.

The fields of travel and international medicine are rapidly changing and growing. The role of occupational and travel health nurses is expanding and should be a focus for the future. At the American Association of Occupational Health Nurses Annual meeting on March 24, 2015, in Boston, five presentations were included in the session, An Update on Travel Vaccines and Issues in Travel and International Medicine. This article summarizes three of the presentations and includes a portion of the information generated by the Centers for Disease Control and Prevention (CDC) included in the fourth presentation. The first section focuses on the Essential Elements of Travel Medicine Programs including the pre-travel care assessment, trip research and risk identification, medication intervention review, non-pharmaceutical and prevention strategies, and post-travel care. The next section is an overview of key issues for business travelers. The growth in the number of international business travelers and unique aspects of business travel are emphasized in a comprehensive travel health program. This section also includes a discussion of expatriates and their special risks identified in recent literature (e.g., an assessment of the significant costs of health events and productivity losses by both business travelers and expatriates). The final section offers a specific example of a vaccine-preventable disease, namely, Japanese encephalitis (JE) virus, and needed changes in JE vaccine recommendations.

The Changing Risk of Japanese Encephalitis for Business Travelers.

Japanese Encephalitis is an often fatal and vaccine preventable disease. New vaccine recommendations are needed due to changes in travel and disease patterns.

Integrating health and safety in the workplace: how closely aligning health and safety strategies can yield measurable benefits.

OBJECTIVE: To better understand how integrating health and safety strategies in the workplace has evolved and establish a replicable, scalable framework for advancing the concept with a system of health and safety metrics, modeled after the Dow Jones Sustainability Index. METHODS: Seven leading national and international programs aimed at creating a culture of health and safety in the workplace were compared and contrasted. RESULTS: A list of forty variables was selected, making it clear there is a wide variety of approaches to integration of health and safety in the workplace. CONCLUSION: Depending on how well developed the culture of health and safety is within a company, there are unique routes to operationalize and institutionalize the integration of health and safety strategies to achieve measurable benefits to enhance the overall health and well-being of workers, their families, and the community.

Tracking low back problems in a major self-insured workforce: toward improvement in the patient's journey.

OBJECTIVE: To assess the cost outcomes of treatment approaches to care for back problems in a major self-insured workforce, using published guidelines to focus on low back pain. METHODS: Longitudinally tracked episodes of three types of International Classification of Diseases, Ninth Revision diagnosis code-identified back problems (n=14,787) during 2001 to 2009. Identified five patterns of care on the basis of the first 6 weeks of claims and compared their total costs per episode with tests that included splits by episode type and duration, use of guidelines, and propensity-derived adjustments. RESULTS: Care congruent with 10 of 11 guidelines was linked to lower total costs. Of the five patterns, complex medical management and chiropractic reported the highest and lowest rates, respectively, of guideline-incongruent use of imaging, surgeries, and medications, and the highest and lowest total costs. CONCLUSIONS: Approaches marked by higher resource utilization and lower guideline congruence are linked to greater low back pain total costs. Total cost is a needed input for guideline development.

Reducing total health burden from 2001 to 2009: an employer counter-trend success story and its implications for health care reform.

OBJECTIVES: To examine total health burden for an employer whose health-related focus is direct and indirect costs. To explore implications for the Final Rule for Accountable Care Organizations recently issued by the Centers for Medicare and Medicaid Services, whose focus includes direct but not indirect costs. METHODS: Used 42 claims and survey-based measures to track this employer's continental US workforce burden in the aggregate and by healthy and selected disease designations from 2001-2002 to 2008-2009. RESULTS: Starting from equivalent baselines, this employer's aggregate total direct costs decreased 16% (8.5% adjusted) whereas comparable US per capita expenditures rose 22.1%. Even larger decreases were recorded in total indirect costs. The healthy and disease designations replicated this pattern. Minimal employee cost shifting occurred. CONCLUSIONS: Attention to direct and indirect costs helped put this employer's health care investment on a markedly more sustainable path than comparable national cost trends. Fully tapping the applicable lessons this and other purchasers have learned will be facilitated by amending the Final Rule to include measures of indirect costs.

The self-reported health and productivity burden of autoimmune disorders at a major self-insured employer.

OBJECTIVES: Examine the self-reported health and productivity burden of three autoimmune disorders: rheumatoid arthritis, psoriasis, and inflammatory bowel disease. METHODS: A 2009 representative survey of a major employer's US workforce, with two approaches for disease identification: (1) self-report and (2) self-report replicated by claims-based International Classification of Diseases, 9th Revision (ICD-9), codes. RESULTS: Self-reported prevalence: rheumatoid arthritis, 4.2%; psoriasis, 3.0%; inflammatory bowel disease, 1.2%. Psoriasis and inflammatory bowel disease replicated rheumatoid arthritis' pattern of health and productivity effects though not as strongly. The three autoimmune disorders combined significantly affected health at all severity levels. They also significantly affected productivity at higher severity but not at no symptom/lower severity levels. CONCLUSIONS: When employees with autoimmune disorders with lower severity/no symptoms do not progress to higher severity, their work performance remains on par with healthy employees. Autoimmune disorders' high impact/low prevalence offers much promise for lowering costs through benefit design.

Managing the burden of chronic obstructive pulmonary disease on workforce health and productivity: upping a leading employer's game.

OBJECTIVE: To develop new evidence for advancing a leading employer's capacity to manage the burden of chronic obstructive pulmonary disease (COPD). METHODS: Retrospective analyses of an integrated database tracking active employees (n = 19,989) from 2001-2009. Tests on 29 measures of direct/indirect costs and drivers examined unique disease burden and impact over time. RESULTS: The costs of COPD exceeded workforce-wide costs by wide margins in 2001-2002. Direct costs linked to the disease rose in 2008-2009; whereas, its indirect costs dropped sharply. Differences between yet-to-be-diagnosed versus diagnosed and newly diagnosed versus established diagnosed groups were directionally consistent on driver and cost measures in 2001-2002. In 2008-2009, these comparisons were similarly consistent on indirect measures but not direct measures. Medication use helped to explain the inconsistencies. DISCUSSION: New action on COPD-oriented unit price escalation, prevention, and medical management concerns raised by these results could strengthen an already exemplary health and productivity program.

Health effects research and regulation of diesel exhaust: an historical overview focused on lung cancer risk.

The mutagenicity of organic solvent extracts from diesel exhaust particulate (DEP), first noted more than 55 years ago, initiated an avalanche of diesel exhaust (DE) health effects research that now totals more than 6000 published studies. Despite an extensive body of results, scientific debate continues regarding the nature of the lung cancer risk posed by inhalation of occupational and environmental DE, with much of the debate focused on DEP. Decades of scientific scrutiny and increasingly stringent regulation have resulted in major advances in diesel engine technologies. The changed particulate matter (PM) emissions in "New Technology Diesel Exhaust (NTDE)" from today's modern low-emission, advanced-technology on-road heavy-duty diesel engines now resemble the PM emissions in contemporary gasoline engine exhaust (GEE) and compressed natural gas engine exhaust more than those in the "traditional diesel exhaust" (TDE) characteristic of older diesel engines. Even with the continued publication of epidemiologic analyses of TDE-exposed populations, this database remains characterized by findings of small increased lung cancer risks and inconsistent evidence of exposure-response trends, both within occupational cohorts and across occupational groups considered to have markedly different exposures (e.g. truckers versus railroad shopworkers versus underground miners). The recently published National Institute for Occupational Safety and Health (NIOSH)-National Cancer Institute (NCI) epidemiologic studies of miners provide some of the strongest findings to date regarding a DE-lung cancer association, but some inconsistent exposure-response findings and possible effects of bias and exposure misclassification raise questions regarding their interpretation. Laboratory animal studies are negative for lung tumors in all species, except for rats under lifetime TDE-exposure conditions with durations and concentrations that lead to "lung overload." The species specificity of the rat lung response to overload, and its occurrence with other particle types, is now well-understood. It is thus generally accepted that the rat bioassay for inhaled particles under conditions of lung overload is not predictive of human lung cancer hazard. Overall, despite an abundance of epidemiologic and experimental data, there remain questions as to whether TDE exposure causes increased lung cancers in humans. An abundance of emissions characterization data, as well as preliminary toxicological data, support NTDE as being toxicologically distinct from TDE. Currently, neither epidemiologic data nor animal bioassay data yet exist that directly bear on NTDE carcinogenic potential. A chronic bioassay of NTDE currently in progress will provide data on whether NTDE poses a carcinogenic hazard, but based on the significant reductions in PM mass emissions and the major changes in PM composition, it has been hypothesized that NTDE has a low carcinogenic potential. When the International Agency for Research on Cancer (IARC) reevaluates DE (along with GEE and nitroarenes) in June 2012, it will be the first authoritative body to assess DE carcinogenic health hazards since the emergence of NTDE and the accumulation of data differentiating NTDE from TDE.

Product stewardship and science: safe manufacture and use of fiber glass.

This paper describes a proactive product stewardship program for glass fibers. That effort included epidemiological studies of workers, establishment of stringent workplace exposure limits, liaison with customers on safe use of products and, most importantly, a research program to evaluate the safety of existing glass fiber products and guide development of new even safer products. Chronic inhalation exposure bioassays were conducted with rodents and hamsters. Amosite and crocidolite asbestos produced respiratory tract cancers as did exposure to "biopersistent" synthetic vitreous fibers. "less biopersistent" glass fibers did not cause respiratory tract cancers. Corollary studies demonstrated the role of slow fiber dissolution rates and biopersistence in cancer induction. These results guided development of safer glass fiber products and have been used in Europe to regulate fibers and by IARC and NTP in classifying fibers. IARC concluded special purpose fibers and refractory ceramic fibers are "possibly carcinogenic to humans" and insulation glass wool, continuous glass filament, rock wool and slag wool are "not classifiable as to their carcinogenicity to human." The NTP's 12th report on carcinogens lists "Certain Glass Wool Fibers (Inhalable)" as "reasonably anticipated to be a human carcinogen." "Certain" in the descriptor refers to "biopersistent" glass fibers and excludes "less biopersistent" glass fibers.

Particulate matter in new technology diesel exhaust (NTDE) is quantitatively and qualitatively very different from that found in traditional diesel exhaust (TDE).

Diesel exhaust (DE) characteristic of pre-1988 engines is classified as a "probable" human carcinogen (Group 2A) by the International Agency for Research on Cancer (IARC), and the U.S. Environmental Protection Agency has classified DE as "likely to be carcinogenic to humans." These classifications were based on the large body of health effect studies conducted on DE over the past 30 or so years. However, increasingly stringent U.S. emissions standards (1988-2010) for particulate matter (PM) and nitrogen oxides (NOx) in diesel exhaust have helped stimulate major technological advances in diesel engine technology and diesel fuel/lubricant composition, resulting in the emergence of what has been termed New Technology Diesel Exhaust, or NTDE. NTDE is defined as DE from post-2006 and older retrofit diesel engines that incorporate a variety of technological advancements, including electronic controls, ultra-low-sulfur diesel fuel, oxidation catalysts, and wall-flow diesel particulate filters (DPFs). As discussed in a prior review (T. W. Hesterberg et al.; Environ. Sci. Technol. 2008, 42, 6437-6445), numerous emissions characterization studies have demonstrated marked differences in regulated and unregulated emissions between NTDE and "traditional diesel exhaust" (TDE) from pre-1988 diesel engines. Now there exist even more data demonstrating significant chemical and physical distinctions between the diesel exhaust particulate (DEP) in NTDE versus DEP from pre-2007 diesel technology, and its greater resemblance to particulate emissions from compressed natural gas (CNG) or gasoline engines. Furthermore, preliminary toxicological data suggest that the changes to the physical and chemical composition of NTDE lead to differences in biological responses between NTDE versus TDE exposure. Ongoing studies are expected to address some of the remaining data gaps in the understanding of possible NTDE health effects, but there is now sufficient evidence to conclude that health effects studies of pre-2007 DE likely have little relevance in assessing the potential health risks of NTDE exposures.

How to align evidence-based benefit design with the employer bottom-line: a case study.

OBJECTIVE: To illustrate how to use evidence-based benefit design (EBD) by presenting the case study of a major manufacturer. METHOD: Key components of the company's measurement and management approach to EBD are introduced. Descriptive results on the direct and indirect cost and utilization trends of the company's US active workforce during 2002 to 2008 are presented. RESULTS: From 1999 to 2002 aggregated to 2008, health care costs dropped sharply, with 2006, 2008, and projected 2009 reporting decreases even as annualized increases in national expenditures approximated 10%. Annualized rates for hospitalizations, office visits, and prescriptions showed corresponding decreases from 2004 to 2008. From 2002 to 2008, workers' compensation/disability and absenteeism costs decreased 38% and 46%, respectively. CONCLUSIONS: These results support the company's direction in health benefit design although further confirmation is needed. Ongoing quality improvement processes are discussed, as are implications for implementing EBD.