Cost-Effective Drug Switch Options After Unsuccessful Treatment With an SSRI for Depression.

OBJECTIVE: Multiple treatment options are available for patients who do not respond to initial treatment for major depressive disorder. Previous results show that bupropion, sertraline, and venlafaxine are comparable in terms of therapeutic effectiveness following unsuccessful treatment with citalopram. In this study, we extended these results by incorporating costs of treatment to determine if one option was more cost-effective relative to others. METHODS: In the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) trial, 727 patients were randomly assigned to a switch drug treatment during level 2; 239 (33%) were assigned to bupropion, 238 (33%) to sertraline, and 250 (34%) to venlafaxine. For each study medication, the total costs included the costs of the medication, other concomitant medication and antidepressants, and health care facility utilization. Effectiveness was measured as remission and response. Cost-effectiveness was assessed as net health benefits. Stochastic analysis was performed by using the bootstrapping method. RESULTS: During level 2, mean medication costs were significantly higher for venlafaxine than for bupropion and sertraline ($968, $607, and $703, respectively). There were no significant differences among the switch medications in costs for other medications and health care facility utilization. Although the total costs were significantly different for the three medications (p=.025), none of the pairwise differences between medications were significant. Also, after jointly estimating costs and effects, the analyses found that net health benefits were not significantly different among the three drugs. CONCLUSIONS: After unsuccessful treatment with citalopram, the switch options of bupropion, sertraline, and venlafaxine were not significantly different from each other in terms of cost-effectiveness.

Escherichia coli O157:H7 Outbreak Associated with Restaurant Beef Grinding.

Escherichia coli O157:H7 is a common cause of foodborne illness in the United States. Beef ground at establishments regulated by the U.S. Department of Agriculture, Food Safety and Inspection Service is routinely tested for E. coli O157:H7. Prior to December 2013, boxed beef product (wholesale cuts of beef, such as beef loin, packaged into bags and boxed for shipping) was not always tested for this pathogen. Downstream processors or retailers may grind the product; and, if the ground beef is not cooked to the recommended temperature, pathogens on the exterior of the beef introduced to the interior through grinding may survive. On 18 October 2013, the Allegheny County Health Department identified two E. coli O157:H7 cases, both of whom were food handlers at restaurant A, a restaurant that ground locally produced boxed beef for hamburgers on site. Case finding was conducted through public messaging, employee surveys, and disease surveillance. All potential cases were interviewed using a standard questionnaire. A confirmed case was defined as laboratory-confirmed E. coli O157:H7 with exposure to restaurant A. A probable case was defined as a patient with compatible symptoms and exposure to restaurant A but without laboratory confirmation. All human and food isolates were characterized by pulsed-field gel electrophoresis and multilocus variable-number tandem repeat analysis. The analysis identified 14 confirmed and 10 probable cases of E. coli; 18 nonintact ground beef samples tested positive for E. coli O157:H7. Nine confirmed cases were restaurant A employees. All confirmed cases recalled eating a restaurant A hamburger in the 10 days before illness onset; most cases reported consuming medium to rare hamburgers. Multiple pulsed-field gel electrophoresis and multilocus variable-number tandem repeat analysis patterns were identified among both the human and ground beef isolates, and the patient isolates matched those found in ground beef samples. Restaurant A voluntarily closed for 1.5 days, changed beef suppliers, ceased grinding beef in-house, and has had no new cases since reopening.

The benefits to all of ensuring equal and timely access to influenza vaccines in poor communities.

When influenza vaccines are in short supply, allocating vaccines equitably among different jurisdictions can be challenging. But justice is not the only reason to ensure that poorer counties have the same access to influenza vaccines as do wealthier ones. Using a detailed computer simulation model of the Washington, D.C., metropolitan region, we found that limiting or delaying vaccination of residents of poorer counties could raise the total number of influenza infections and the number of new infections per day at the peak of an epidemic throughout the region-even in the wealthier counties that had received more timely and abundant vaccine access. Among other underlying reasons, poorer counties tend to have high-density populations and more children and other higher-risk people per household, resulting in more interactions and both increased transmission of influenza and greater risk for worse influenza outcomes. Thus, policy makers across the country, in poor and wealthy areas alike, have an incentive to ensure that poorer residents have equal access to vaccines.

Would school closure for the 2009 H1N1 influenza epidemic have been worth the cost?: a computational simulation of Pennsylvania.

BACKGROUND: During the 2009 H1N1 influenza epidemic, policy makers debated over whether, when, and how long to close schools. While closing schools could have reduced influenza transmission thereby preventing cases, deaths, and health care costs, it may also have incurred substantial costs from increased childcare needs and lost productivity by teachers and other school employees. METHODS: A combination of agent-based and Monte Carlo economic simulation modeling was used to determine the cost-benefit of closing schools (vs. not closing schools) for different durations (range: 1 to 8 weeks) and symptomatic case incidence triggers (range: 1 to 30) for the state of Pennsylvania during the 2009 H1N1 epidemic. Different scenarios varied the basic reproductive rate (R(0)) from 1.2, 1.6, to 2.0 and used case-hospitalization and case-fatality rates from the 2009 epidemic. Additional analyses determined the cost per influenza case averted of implementing school closure. RESULTS: For all scenarios explored, closing schools resulted in substantially higher net costs than not closing schools. For R(0) = 1.2, 1.6, and 2.0 epidemics, closing schools for 8 weeks would have resulted in median net costs of $21.0 billion (95% Range: $8.0 - $45.3 billion). The median cost per influenza case averted would have been $14,185 ($5,423 - $30,565) for R(0) = 1.2, $25,253 ($9,501 - $53,461) for R(0) = 1.6, and $23,483 ($8,870 - $50,926) for R(0) = 2.0. CONCLUSIONS: Our study suggests that closing schools during the 2009 H1N1 epidemic could have resulted in substantial costs to society as the potential costs of lost productivity and childcare could have far outweighed the cost savings in preventing influenza cases.

Probabilistic case detection for disease surveillance using data in electronic medical records.

This paper describes a probabilistic case detection system (CDS) that uses a Bayesian network model of medical diagnosis and natural language processing to compute the posterior probability of influenza and influenza-like illness from emergency department dictated notes and laboratory results. The diagnostic accuracy of CDS for these conditions, as measured by the area under the ROC curve, was 0.97, and the overall accuracy for NLP employed in CDS was 0.91.

Probabilistic, Decision-theoretic Disease Surveillance and Control.

The Pittsburgh Center of Excellence in Public Health Informatics has developed a probabilistic, decision-theoretic system for disease surveillance and control for use in Allegheny County, PA and later in Tarrant County, TX. This paper describes the software components of the system and its knowledge bases. The paper uses influenza surveillance to illustrate how the software components transform data collected by the healthcare system into population level analyses and decision analyses of potential outbreak-control measures.

Simulating school closure strategies to mitigate an influenza epidemic.

BACKGROUND: There remains substantial debate over the impact of school closure as a mitigation strategy during an influenza pandemic. The ongoing 2009 H1N1 influenza pandemic has provided an unparalleled opportunity to test interventions with the most up-to-date simulations. METHODS: To assist the Allegheny County Health Department during the 2009 H1N1 influenza pandemic, the University of Pittsburgh Models of Infectious Disease Agents Study group employed an agent-based computer simulation model (ABM) of Allegheny County, Pennsylvania, to explore the effects of various school closure strategies on mitigating influenza epidemics of different reproductive rates (R0). RESULTS: Entire school system closures were not more effective than individual school closures. Any type of school closure may need to be maintained throughout most of the epidemic (ie, at least 8 weeks) to have any significant effect on the overall serologic attack rate. In fact, relatively short school closures (ie, 2 weeks or less) may actually slightly increase the overall attack rate by returning susceptible students back into schools in the middle of the epidemic. Varying the illness threshold at which school closures are triggered did not seem to have substantial impact on the effectiveness of school closures, suggesting that short delays in closing schools should not cause concern. CONCLUSIONS: School closures alone may not be able to quell an epidemic but, when maintained for at least 8 weeks, could delay the epidemic peak for up to a week, providing additional time to implement a second more effective intervention such as vaccination.

The effect of training on question formulation among public health practitioners: results from a randomized controlled trial.

OBJECTIVE: To improve understanding of the information-seeking behaviors of public health professionals, the authors conducted this randomized controlled trial involving sixty participants to determine whether library and informatics training, with an emphasis on PubMed searching skills, increased the frequency and sophistication of participants' practice-related questions. METHODS: The intervention group (n = 34) received evidence-based public health library and informatics training first, whereas the control group (n = 26) received identical training two weeks later. The frequency and sophistication of the questions generated by both intervention and control groups during the interim two-week period served as the basis for comparison. RESULTS: The intervention group reported an average of almost 1.8 times more questions than those reported by the control group (1.24 vs. 0.69 questions per participant); however, this difference did not reach statistical significance. The intervention group overall produced more sophisticated (foreground) questions than the control group (18 vs. 9); however, this difference also did not reach statistical significance. CONCLUSION: The training provided in the current study seemed to prompt public health practitioners to identify and articulate questions more often. Training appears to create the necessary precondition for increased information-seeking behavior among public health professionals.

Outbreak of lepidopterism at a Boy Scout camp.

BACKGROUND: Lepidopterism refers to moth- or butterfly-associated illness, including contact dermatitis, urticaria, and occasional systemic reactions. Lepidopterism outbreaks are rare. OBJECTIVE: To investigate a lepidopterism outbreak associated with caterpillars of the Douglas-fir tussock moth (DFTM; Orgyia pseudotsugata) among Boy Scouts attending summer camp in New Mexico. METHODS: Retrospective cohort analysis; environmental investigation. RESULTS: Attendees were primarily male (100/107; 94%) and less than 18 years old (82/107; 77%). Itch, rash, or hives were reported by 56 of 102 (55%) of campers. Patients were more likely to report direct caterpillar contact (relative risk [RR]: 2.7; 95% confidence interval [CI], 1.3-5.5); playing a caterpillar-flicking game (RR: 1.9; 95% CI, 1.1-3.4); and sleeping at campsite 6, where caterpillars were most numerous (RR: 1.7; 95% CI, 1.3-2.4). All patients recovered. LIMITATIONS: Data on disease status and risk factors were collected retrospectively. CONCLUSION: Modifying behaviors associated with lepidopterism and avoiding areas of heavy infestation can reduce illness risk.

Assessment of urinary metals following exposure to a large vegetative fire, New Mexico, 2000.

INTRODUCTION: In May 2000, a vegetative fire burned 47,000 acres in northern New Mexico, including 7500 acres of land administered by the Los Alamos National Laboratory. We evaluated potential human exposures from the fire. METHODS: We surveyed two populations (firefighters and the general population) in four cities for urine heavy metal concentrations. Reference concentrations were based on the Third National Health and Nutrition Examination Survey (NHANES III). Multivariate linear regression assessed the association of urinary metal concentrations with smoke exposure. We also performed isotopic analysis of uranium and cesium on a subset of specimens. RESULTS: A total of 92 firefighters and 135 nonfirefighters participated. In both populations, urinary nickel, cesium, chromium, and uranium concentrations were greater than expected compared with NHANES III reference values. No values required immediate medical follow-up. Regression analysis demonstrated that for National Guard members, arsenic and cadmium levels were significantly related to smoke exposure, and for firefighters, cesium and arsenic levels were significantly related to exposure; however, only for cesium in National Guard members was this association in the positive direction. Isotopic analysis demonstrated that the cesium and uranium were naturally occurring. CONCLUSIONS: Some people had spot urine metal concentrations above nationally derived reference values, and values for some metals were associated with smoke exposure. These associations had little public health or clinical importance. Studies of exposures resulting from vegetative fires are difficult, and careful consideration should be given to the technical and communication processes at the outset of a fire exposure investigation. Recommendations for future investigations include testing as soon as possible during or after a fire, and early clinical consultation with a medical toxicologist.