Liver injury in hospitalized patients with COVID-19: An International observational cohort study.

BACKGROUND: Using a large dataset, we evaluated prevalence and severity of alterations in liver enzymes in COVID-19 and association with patient-centred outcomes. METHODS: We included hospitalized patients with confirmed or suspected SARS-CoV-2 infection from the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) database. Key exposure was baseline liver enzymes (AST, ALT, bilirubin). Patients were assigned Liver Injury Classification score based on 3 components of enzymes at admission: Normal; Stage I) Liver injury: any component between 1-3x upper limit of normal (ULN); Stage II) Severe liver injury: any component ≥3x ULN. Outcomes were hospital mortality, utilization of selected resources, complications, and durations of hospital and ICU stay. Analyses used logistic regression with associations expressed as adjusted odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Of 17,531 included patients, 46.2% (8099) and 8.2% (1430) of patients had stage 1 and 2 liver injury respectively. Compared to normal, stages 1 and 2 were associated with higher odds of mortality (OR 1.53 [1.37-1.71]; OR 2.50 [2.10-2.96]), ICU admission (OR 1.63 [1.48-1.79]; OR 1.90 [1.62-2.23]), and invasive mechanical ventilation (OR 1.43 [1.27-1.70]; OR 1.95 (1.55-2.45). Stages 1 and 2 were also associated with higher odds of developing sepsis (OR 1.38 [1.27-1.50]; OR 1.46 [1.25-1.70]), acute kidney injury (OR 1.13 [1.00-1.27]; OR 1.59 [1.32-1.91]), and acute respiratory distress syndrome (OR 1.38 [1.22-1.55]; OR 1.80 [1.49-2.17]). CONCLUSIONS: Liver enzyme abnormalities are common among COVID-19 patients and associated with worse outcomes.

Social contact patterns relevant for infectious disease transmission in Cambodia.

Social mixing patterns are key determinants of infectious disease transmission. Mathematical models parameterised with empirical data from contact pattern surveys have played an important role in understanding epidemic dynamics and informing control strategies, including for SARS-CoV-2. However, there is a paucity of data on social mixing patterns in many settings. We conducted a community-based survey in Cambodia in 2012 to characterise mixing patterns and generate setting-specific contact matrices according to age and urban/rural populations. Data were collected using a diary-based approach from 2016 participants, selected by stratified random sampling. Contact patterns were highly age-assortative, with clear intergenerational mixing between household members. Both home and school were high-intensity contact settings, with 27.7% of contacts occurring at home with non-household members. Social mixing patterns differed between rural and urban residents; rural participants tended to have more intergenerational mixing, and a higher number of contacts outside of home, work or school. Participants had low spatial mobility, with 88% of contacts occurring within 1 km of the participants' homes. These data broaden the evidence-base on social mixing patterns in low and middle-income countries and Southeast Asia, and highlight within-country heterogeneities which may be important to consider when modelling the dynamics of pathogens transmitted via close contact.

Antenatal corticosteroids reduce neonatal mortality in settings without assisted ventilatory support: a retrospective cohort study of early preterm births on the Thailand-Myanmar border.

Background: Prematurity is the highest risk for under-five mortality globally. The aim of the study was to assess the effect of antenatal dexamethasone on neonatal mortality in early preterm in a resource-constrained setting without assisted ventilation. Methods: This retrospective (2008-2013) cohort study in clinics for refugees/migrants on the Thai-Myanmar border included infants born <34 weeks gestation at home, in, or on the way to the clinic. Dexamethasone, 24 mg (three 8 mg intramuscular doses, every 8 hours), was prescribed to women at risk of preterm birth (28 to <34 weeks). Appropriate newborn care was available: including oxygen but not assisted ventilation. Mortality and maternal fever were compared by the number of doses (complete: three, incomplete (one or two), or no dose). A sub-cohort participated in neurodevelopmental testing at one year. Results: Of 15,285 singleton births, 240 were included: 96 did not receive dexamethasone and 144 received one, two or three doses (56, 13 and 75, respectively). Of live-born infants followed to day 28, (n=168), early neonatal and neonatal mortality/1,000 livebirths (95%CI) with complete dosing was 217 (121-358) and 304 (190-449); compared to 394 (289-511) and 521 (407-633) with no dose. Compared to complete dosing, both incomplete and no dexamethasone were associated with elevated adjusted ORs 4.09 (1.39 to 12.00) and 3.13 (1.14 to 8.63), for early neonatal death. By contrast, for neonatal death, while there was clear evidence that no dosing was associated with higher mortality, adjusted OR 3.82 (1.42 to 10.27), the benefit of incomplete dosing was uncertain adjusted OR 1.75 (0.63 to 4.81). No adverse impact of dexamethasone on infant neurodevelopmental scores (12 months) or maternal fever was observed. Conclusions: Neonatal mortality reduction is possible with complete dexamethasone dosing in pregnancies at risk of preterm birth in settings without capacity to provide assisted ventilation.

A scoping review of antibiotic use practices and drivers of inappropriate antibiotic use in animal farms in WHO Southeast Asia region.

Antibiotic use (ABU) plays an important role in the proliferation of antimicrobial resistance (AMR). Global antimicrobial consumption in food production is projected to rise by 67% from 2010 to 2030, but available estimates are limited by the scarcity of ABU data and absence of global surveillance systems. The WHO South-East Asia (WHO SEA) region is at high risk of emergence of AMR, likely driven by intensifying farm operations and worsening ABU hotspots. However, little is known about farm-level ABU practices in the region. To summarize emerging evidence and research gaps, we conducted a scoping review of ABU practices following the Arksey and O'Malley methodological framework. We included studies published between 2010 and 2021 on farm-level ABU/AMR in the 11 WHO SEA member states, and databases were last searched on 31 October 2021. Our search strategy identified 184 unique articles, and 25 publications underwent full-text eligibility assessment. Seventeen studies, reported in 18 publications, were included in the scoping review. We found heterogeneity in the categorizations, definitions, and ABU characterization methods used across studies and farm types. Most studies involved poultry, pig, and cattle farms, and only one study examined aquaculture. Most studies evaluated ABU prevalence by asking respondents about the presence or absence of ABU in the farm. Only two studies quantified antibiotic consumption, and sampling bias and lack of standardized data collection methods were identified as key limitations. Emerging evidence that farm workers had difficulty differentiating antibiotics from other substances contributed to the uncertainty about the reliability of self-reported data without other validation techniques. ABU for growth promotion and treatment were prevalent. We found a large overlap in the critically important antibiotics used in farm animals and humans. The ease of access to antibiotics compounded by the difficulties in accessing quality veterinary care and preventive services likely drive inappropriate ABU in complex ways.

Influence of the meteorological conditions and some pollutants on PM10 concentrations in Lamphun, Thailand.

Particulate matter (PM) has been occurring regularly during the dry season in the upper north of Thailand including Lamphun Province that might be influenced by various factors including climatologic and other pollutants. This paper aims to investigate the climatologic and gaseous factors influencing the occurrence of PM10 concentration using Pollution Control Department (PCD) data. The secondary data of 2009 to 2017 obtained from the PCD was used for analysis. We used descriptive statistics, Pearson's correlation coefficient, multiple regression and graphic presentation using R program (R packages of 'open air' and 'ncdf4') and Microsoft Excel Spreadsheet®. In addition, the periodic measurement of PM2.5 and PM10 were investigated to determine the ratio of PM2.5/PM10. The results indicated that haze episodes (daily PM10 concentration always over the PCD standard) normally occur during the dry season from February to April. The maximum concentration was always found in March. The PM10 concentration was negatively associated with relative humidity and temperature while the PM10 concentration showed a strongly positive association with CO and NO2 concentration with correlation values of 0.70 and 0.57, respectively. Furthermore, we found CO and PM10 concentration was associated with ozone concentration. This finding will benefit local communities and the public health sector to provide a warning system for preparation and response plans to react to PM10 episodes in their responsible areas.

One Health drivers of antibacterial resistance: Quantifying the relative impacts of human, animal and environmental use and transmission.

OBJECTIVES: Antibacterial resistance (ABR) is a major global health security threat, with a disproportionate burden on lower-and middle-income countries (LMICs). It is not understood how 'One Health', where human health is co-dependent on animal health and the environment, might impact the burden of ABR in LMICs. Thailand's 2017 "National Strategic Plan on Antimicrobial Resistance" (NSP-AMR) aims to reduce AMR morbidity by 50% through 20% reductions in human and 30% in animal antibacterial use (ABU). There is a need to understand the implications of such a plan within a One Health perspective. METHODS: A model of ABU, gut colonisation with extended-spectrum beta-lactamase (ESBL)-producing bacteria and transmission was calibrated using estimates of the prevalence of ESBL-producing bacteria in Thailand. This model was used to project the reduction in human ABR over 20 years (2020-2040) for each One Health driver, including individual transmission rates between humans, animals and the environment, and to estimate the long-term impact of the NSP-AMR intervention. RESULTS: The model predicts that human ABU was the most important factor in reducing the colonisation of humans with resistant bacteria (maximum 65.7-99.7% reduction). The NSP-AMR is projected to reduce human colonisation by 6.0-18.8%, with more ambitious targets (30% reductions in human ABU) increasing this to 8.5-24.9%. CONCLUSIONS: Our model provides a simple framework to explain the mechanisms underpinning ABR, suggesting that future interventions targeting the simultaneous reduction of transmission and ABU would help to control ABR more effectively in Thailand.

Non-linear effect of different humidity types on scrub typhus occurrence in endemic provinces, Thailand.

BACKGROUND: Reported monthly scrub typhus (ST) cases in Thailand has an increase in the number of cases during 2009-2014. Humidity is a crucial climatic factor for the survival of chiggers, which is the disease vectors. The present study was to determine the role of humidity in ST occurrence in Thailand and its delayed effect. METHODS: We obtained the climate data from the Department of Meteorology, the disease data from Ministry of Public Health. Negative binomial regression combined with a distributed lag non-linear model (NB-DLNM) was employed to determine the non-linear effects of different types of humidity on the disease. This model controlled overdispersion and confounder, including seasonality, minimum temperature, and cumulative total rainwater. RESULTS: The occurrence of the disease in the 6-year period showed the number of cases gradually increased summer season (Mid-February - Mid-May) and then reached a plateau during the rainy season (Mid-May - Mid-October) and then steep fall after the cold season (Mid-October - Mid-February). The high level (at 70%) of minimum relative humidity (RHmin) was associated with a 33% (RR 1.33, 95% CI 1.13-1.57) significant increase in the number of the disease; a high level (at 14 g/m3) of minimum absolute humidity (AHmin) was associated with a 30% (RR 1.30, 95% CI 1.14-1.48); a high level (at 1.4 g/kg) of minimum specific humidity (SHmin) was associated with a 28% (RR 1.28, 95% CI 1.04-1.57). The significant effects of these types of humidity occurred within the past month. CONCLUSION: Humidity played a significant role in enhancing ST cases in Thailand, particularly at a high level and usually occurred within the past month. NB-DLNM had good controlled for the overdispersion and provided the precise estimated relative risk of non-linear associations. Results from this study contributed the evidence to support the Ministry of Public Health on warning system which might be useful for public health intervention and preparation in Thailand.

System dynamics modelling of health workforce planning to address future challenges of Thailand's Universal Health Coverage.

BACKGROUND: System dynamics (SD) modelling can inform policy decisions under Thailand's Universal Health Coverage. We report on this thinking approach to Thailand's strategic health workforce planning for the next 20 years (2018-2037). METHODS: A series of group model building (GMB) sessions involving 110 participants from multi-sectors of Thailand's health systems was conducted in 2017 and 2018. We facilitated policymakers, administrators, practitioners and other stakeholders to co-create a causal loop diagram (CLD) representing a shared understanding of why the health workforce's demands and supplies in Thailand were mismatched. A stock and flow diagram (SFD) was also co-created for testing the consequences of policy options by simulation modelling. RESULTS: The simulation modelling found hospital utilisation created a vicious cycle of constantly increasing demands for hospital care and a constant shortage of healthcare providers. Moreover, hospital care was not designed for effectively dealing with the future demands of ageing populations and prevalent chronic illness. Hence, shifting emphasis to professions that can provide primary care, intermediate care, long-term care, palliative care, and end-of-life care can be more effective. CONCLUSIONS: Our SD modelling confirmed that shifting the care models to address the changing health demands can be a high-leverage policy of health workforce planning, although very difficult to implement in the short term. of health workforce planning, although very difficult to implement in the short term.

Climate Warming and Occupational Heat and Hot Environment Standards in Thailand.

BACKGROUND: During the period 2001 to 2016, the maximum temperatures in Thailand rose from 38-41oC to 42-44oC. The current occupational heat exposure standard of Thailand issued in 2006 is based on wet bulb globe temperature (WBGT) defined for three workload levels without a work-rest regimen. This study examined whether the present standard still protects most workers. METHODS: The sample comprised 168 heat acclimatized workers (90 in construction sites, 78 in foundries). Heart rate and auditory canal temperature were recorded continuously for 2 hours. Workplace WBGT, relative humidity, and wind velocity were monitored, and the participants' workloads were estimated. Heat-related symptoms and signs were collected by a questionnaire. RESULTS: Only 55% of the participants worked in workplaces complying with the heat standard. Of them, 79% had auditory canal temperature ≤ 38.5oC, compared with only 58% in noncompliant workplaces. 18% and 43% of the workers in compliant and noncompliant workplaces, respectively, had symptoms from heat stress, the trend being similar across all workload levels. An increase of one degree (C) in WBGT was associated with a 1.85-fold increase (95% confidence interval: 1.44-2.48) in odds for having symptoms. CONCLUSION: Compliance with the current occupational heat standard protects 4/5 of the workers, whereas noncompliance reduces this proportion to one half. The reasons for noncompliance include the gaps and ambiguities in the law. The law should specify work/rest schedules; outdoor work should be identified as an occupational heat hazard; and the staff should include occupational personnel to manage heat stress in establishments involving heat exposure.

Predicted Impact of COVID-19 on Neglected Tropical Disease Programs and the Opportunity for Innovation.

Due to the COVID-19 pandemic, many key neglected tropical disease (NTD) activities have been postponed. This hindrance comes at a time when the NTDs are progressing towards their ambitious goals for 2030. Mathematical modelling on several NTDs, namely gambiense sleeping sickness, lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiases (STH), trachoma, and visceral leishmaniasis, shows that the impact of this disruption will vary across the diseases. Programs face a risk of resurgence, which will be fastest in high-transmission areas. Furthermore, of the mass drug administration diseases, schistosomiasis, STH, and trachoma are likely to encounter faster resurgence. The case-finding diseases (gambiense sleeping sickness and visceral leishmaniasis) are likely to have fewer cases being detected but may face an increasing underlying rate of new infections. However, once programs are able to resume, there are ways to mitigate the impact and accelerate progress towards the 2030 goals.

Contact Mixing Patterns and Population Movement among Migrant Workers in an Urban Setting in Thailand.

Data relating to contact mixing patterns among humans are essential for the accurate modeling of infectious disease transmission dynamics. Here, we describe contact mixing patterns among migrant workers in urban settings in Thailand, based on a survey of 369 migrant workers of three nationalities. Respondents recorded their demographic data, including age, sex, nationality, workplace, income, and education. Each respondent chose a single day to record their contacts; this resulted in a total of more than 8300 contacts. The characteristics of contacts were recorded, including their age, sex, nationality, location of contact, and occurrence of physical contact. More than 75% of all contacts occurred among migrants aged 15 to 39 years. The contacts were highly clustered in this age group among migrant workers of all three nationalities. There were far fewer contacts between migrant workers with younger and older age groups. The pattern varied slightly among different nationalities, which was mostly dependent upon the types of jobs taken. Half of migrant workers always returned to their home country at most once a year and on a seasonal basis. The present study has helped us gain a better understanding of contact mixing patterns among migrant workers in urban settings. This information is useful both when simulating disease epidemics and for guiding optimal disease control strategies among this vulnerable section of the population.

Cost-effectiveness modelling studies of all preventive measures against rabies: A systematic review.

Rabies is one of the most feared infectious diseases worldwide, predominantly occurring in Asia and Africa where rabies is endemic in domestic dog populations. Whereas previous studies have demonstrated mass dog vaccination and post-exposure prophylaxis (PEP) as the most effective control strategies, successful rabies elimination has yet to be realized as these recognized effective interventions continue to face challenges of limited accessibility. In the light of new evidence towards improving programmatic feasibility and clinical practice in rabies control especially among endemic countries, a systematic review was undertaken to identify cost-effectiveness modelling studies of rabies preventive measures and to provide a critical review of published evidence through comparative evaluation and model quality assessment, and a synthesis of key findings based thereon. Our search through MEDLINE and SCOPUS identified a total of 17 studies which mostly focused on estimating the impact of increasing PEP and pre-exposure prophylaxis (PrEP) access, human rabies elimination scenarios using mass dog vaccinations only or complemented with PEP strategy. While no significant methodological inconsistency across studies was identified and the extent of reporting is generally high, we note several points for quality and internal validity improvement. Assessment of modelling approach showed that decision tree models had similar pathways. The results of the studies suggest that interventions would be cost-effective at the cost-effectiveness threshold of 1 to 3 times per capita Gross Domestic Product (GDP) as recommended by the Commission on Macroeconomics and Health's GDP based thresholds, compared with no intervention in rabies endemic countries. When compared across studies which reported incremental cost-effectiveness ratio (ICER) as cost per QALY gained or DALY averted in international dollars adjusted by purchasing power parity conversion rate, PEP vaccination yields less cost per DALY averted or QALY gained due to one year-horizon assessment compared to canine vaccination at 4- or 10-year-time horizon.

The impact of transmission dynamics of rabies control: Systematic review.

The public health and economic burden of rabies has led to major intersectoral initiatives worldwide to reduce its burden. Over the last decade, the impact of rabies prevention and control programmes in real-world settings has become increasingly evident, especially in countries where most rabies exposures and deaths occur, but they have yet to successfully eradicate rabies due to limited access to health care services. We aimed to systematically review published transmission dynamic modelling studies of rabies in both humans and dogs with a focus on studies which estimated the epidemiological and economic impact of different preventive measures. The findings are intended to inform the World Health Organization's (WHO) Strategic Advisory Group of Experts on Immunization (SAGE) to improve programmatic feasibility and clinical practice in rabies. Medline and Scopus were systematically searched for peer-reviewed articles which were published up to 14th June 2017. In addition, studies identified from a meeting of the WHO Expert Consultation on Rabies on 26-28th April 2017 in Bangkok, Thailand were added, resulting in 19 articles which were included in the review. Results from the disease modelling indicated that the basic reproduction number was low (less than 2 in all but one study). All studies found that rabies control through canine vaccination was likely to be effective in terms of reducing the incidence of rabies in dogs and/or humans, with most studies suggesting 70% annual coverage was adequate. Vaccine coverage, dog density and birth rate were identified as crucial factors influencing the effectiveness of the interventions. In conclusion, the findings from this review suggest that rabies control through canine vaccination is likely to be effective in reducing the incidence of rabies. Vaccine coverage, dog density and canine birth rate were identified as critical factors influencing the effectiveness of vaccination interventions.

Relationships between Meteorological Parameters and Particulate Matter in Mae Hong Son Province, Thailand.

Meteorological parameters play an important role in determining the prevalence of ambient particulate matter (PM) in the upper north of Thailand. Mae Hong Son is a province located in this region and which borders Myanmar. This study aimed to determine the relationships between meteorological parameters and ambient concentrations of particulate matter less than 10 µm in diameter (PM10) in Mae Hong Son. Parameters were measured at an air quality monitoring station, and consisted of PM10, carbon monoxide (CO), ozone (O3), and meteorological factors, including temperature, rainfall, pressure, wind speed, wind direction, and relative humidity (RH). Nine years (2009⁻2017) of pollution and climate data obtained from the Thai Pollution Control Department (PCD) were used for analysis. The results of this study indicate that PM10 is influenced by meteorological parameters; high concentration occurred during the dry season and northeastern monsoon seasons. Maximum concentrations were always observed in March. The PM10 concentrations were significantly related to CO and O3 concentrations and to RH, giving correlation coefficients of 0.73, 0.39, and -0.37, respectively (p-value < 0.001). Additionally, the hourly PM10 concentration fluctuated within each day. In general, it was found that the reporting of daily concentrations might be best suited to public announcements and presentations. Hourly concentrations are recommended for public declarations that might be useful for warning citizens and organizations about air pollution. Our findings could be used to improve the understanding of PM10 concentration patterns in Mae Hong Son and provide information to better air pollution measures and establish a warning system for the province.

Seasonal influenza vaccination for children in Thailand: a cost-effectiveness analysis.

BACKGROUND: Seasonal influenza is a major cause of mortality worldwide. Routine immunization of children has the potential to reduce this mortality through both direct and indirect protection, but has not been adopted by any low- or middle-income countries. We developed a framework to evaluate the cost-effectiveness of influenza vaccination policies in developing countries and used it to consider annual vaccination of school- and preschool-aged children with either trivalent inactivated influenza vaccine (TIV) or trivalent live-attenuated influenza vaccine (LAIV) in Thailand. We also compared these approaches with a policy of expanding TIV coverage in the elderly. METHODS AND FINDINGS: We developed an age-structured model to evaluate the cost-effectiveness of eight vaccination policies parameterized using country-level data from Thailand. For policies using LAIV, we considered five different age groups of children to vaccinate. We adopted a Bayesian evidence-synthesis framework, expressing uncertainty in parameters through probability distributions derived by fitting the model to prospectively collected laboratory-confirmed influenza data from 2005-2009, by meta-analysis of clinical trial data, and by using prior probability distributions derived from literature review and elicitation of expert opinion. We performed sensitivity analyses using alternative assumptions about prior immunity, contact patterns between age groups, the proportion of infections that are symptomatic, cost per unit vaccine, and vaccine effectiveness. Vaccination of children with LAIV was found to be highly cost-effective, with incremental cost-effectiveness ratios between about 2,000 and 5,000 international dollars per disability-adjusted life year averted, and was consistently preferred to TIV-based policies. These findings were robust to extensive sensitivity analyses. The optimal age group to vaccinate with LAIV, however, was sensitive both to the willingness to pay for health benefits and to assumptions about contact patterns between age groups. CONCLUSIONS: Vaccinating school-aged children with LAIV is likely to be cost-effective in Thailand in the short term, though the long-term consequences of such a policy cannot be reliably predicted given current knowledge of influenza epidemiology and immunology. Our work provides a coherent framework that can be used for similar analyses in other low- and middle-income countries.

Mortality attributable to seasonal influenza A and B infections in Thailand, 2005-2009: a longitudinal study.

Influenza epidemiology differs substantially in tropical and temperate zones, but estimates of seasonal influenza mortality in developing countries in the tropics are lacking. We aimed to quantify mortality due to seasonal influenza in Thailand, a tropical middle-income country. Time series of polymerase chain reaction-confirmed influenza infections between 2005 and 2009 were constructed from a sentinel surveillance network. These were combined with influenza-like illness data to derive measures of influenza activity and relationships to mortality by using a Bayesian regression framework. We estimated 6.1 (95% credible interval: 0.5, 12.4) annual deaths per 100,000 population attributable to influenza A and B, predominantly in those aged ≥60 years, with the largest contribution from influenza A(H1N1) in 3 out of 4 years. For A(H3N2), the relationship between influenza activity and mortality varied over time. Influenza was associated with increases in deaths classified as resulting from respiratory disease (posterior probability of positive association, 99.8%), cancer (98.6%), renal disease (98.0%), and liver disease (99.2%). No association with circulatory disease mortality was found. Seasonal influenza infections are associated with substantial mortality in Thailand, but evidence for the strong relationship between influenza activity and circulatory disease mortality reported in temperate countries is lacking.

An evaluation of usage patterns, effectiveness and cost of the national smoking cessation quitline in Thailand.

BACKGROUND: Telephone-based smoking cessation services (quitlines) offering counselling for smoking cessation without nicotine replacement therapy may be important components of tobacco control efforts in low and middle income countries, but evaluations in such resource-limited settings are lacking. We aimed to evaluate the usage, effectiveness and cost of the Thailand National Quitline (TNQ). METHODS: Analysis of retrospective data for callers to the TNQ between 2009 and 2012 and a follow-up survey in 1161 randomly selected callers. RESULTS: Between 2009 and 2012 there were 116 862 callers to the TNQ; 36 927 received counselling and at least one follow-up call. Compared with smokers in the general population, callers were younger, more highly educated, more likely to be students, and more likely to smoke cigarettes rather than roll-your-own tobacco. Continuous abstinence rates at 1, 3 and 6 months after calling were 49.9%, 38.0% and 33.1%. The predicted rate at 12 months was 19.54% (95% CI 14.55 to 26.24). Average cost per completed counselling was $31 and the average cost per quitter was $253. Assuming all (and two-thirds) TNQ callers who succeed in quitting would have failed to quit without the assistance of the TNQ, cumulative life years saved (LYS) for the 4-year period were 57 238 (36 733) giving a cost per LYS of $32 (50) (about 7.93 LYS per quitter) and an estimated return on investment over 4 years of 9.01 (5.78). CONCLUSIONS: A low-cost quitline without nicotine replacement therapy is a promising model for smoking cessation services and likely to offer good value for money in Thailand.

Cost-utility analysis of 10- and 13-valent pneumococcal conjugate vaccines: protection at what price in the Thai context?

OBJECTIVE: This study aims to evaluate the costs and outcomes of offering the 10-valent pneumococcal conjugate vaccine (PCV10) and 13-valent pneumococcal conjugate vaccine (PCV13) in Thailand compared to the current situation of no PCV vaccination. METHODS: Two vaccination schedules were considered: two-dose primary series plus a booster dose (2+1) and three-dose primary series plus a booster dose (3+1). A cost-utility analysis was conducted using a societal perspective. A Markov simulation model was used to estimate the relevant costs and health outcomes for a lifetime horizon. Costs were collected and values were calculated for the year 2010. The results were reported as incremental cost-effectiveness ratios (ICERs) in Thai Baht (THB) per quality adjusted life year (QALY) gained, with future costs and outcomes being discounted at 3% per annum. One-way sensitivity analysis and probabilistic sensitivity analysis using a Monte Carlo simulation were performed to assess parameter uncertainty. RESULTS: Under the base case-scenario of 2+1 dose schedule and a five-year protection, without indirect vaccine effects, the ICER for PCV10 and PCV13 were THB 1,368,072 and THB 1,490,305 per QALY gained, respectively. With indirect vaccine effects, the ICER of PCV10 was THB 519,399, and for PCV13 was THB 527,378. The model was sensitive to discount rate, the change in duration of vaccine protection and the incidence of pneumonia for all age groups. CONCLUSIONS: At current prices, PCV10 and PCV13 are not cost-effective in Thailand. Inclusion of indirect vaccine effects substantially reduced the ICERs for both vaccines, but did not result in cost effectiveness.

Analysis of 2009 pandemic influenza A/H1N1 outcomes in 19 European countries: association with completeness of national strategic plans.

OBJECTIVE: To describe changes in reported influenza activity associated with the 2009 H1N1 pandemic in European countries and determine whether there is a correlation between these changes and completeness of national strategic pandemic preparedness. DESIGN: A retrospective correlational study. SETTING: Countries were included if their national strategic plans had previously been analysed and if weekly influenza-like illness (ILI) data from sentinel networks between week 21, 2006 and week 20, 2010 were more than 50% complete. OUTCOME MEASURES: For each country we calculated three outcomes: the percentage change in ILI peak height during the pandemic relative to the prepandemic mean; the timing of the ILI peak and the percentage change in total cases relative to the prepandemic mean. Correlations between these outcomes and completeness of a country's national strategic pandemic preparedness plan were assessed using the Pearson product-moment correlation coefficient. RESULTS: Nineteen countries were included. The ILI peak occurred earlier than the mean seasonal peak in 17 countries. In 14 countries the pandemic peak was higher than the seasonal peak, though the difference was large only in Norway, the UK and Greece. Nine countries experienced more total ILI cases during the pandemic compared with the mean for prepandemic years. Five countries experienced two distinct pandemic peaks. There was no clear pattern of correlation between overall completeness of national strategic plans and pandemic influenza outcome measures and no evidence of association between these outcomes and components of pandemic plans that might plausibly affect influenza outcomes (public health interventions, vaccination, antiviral use, public communication). Amongst the 17 countries with a clear pandemic peak, only the correlation between planning for essential services and change in total ILI cases significantly differed from zero: correlation coefficient (95% CI) 0.50 (0.02, 0.79). CONCLUSIONS: The diversity of pandemic influenza outcomes across Europe is not explained by the marked variation in the completeness of pandemic plans.