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Kwon S, Casleton BG, Rivera GZ, Gella MM, Winkler EL, Kieffer JW, Osuna AB, Casey TM, Yun HC, Marcus JE. Infectious etiologies among post-donation deferrals in a military blood donation center. Transfusion 2023; 63:2265-2272. [PMID: 37850496 DOI: 10.1111/trf.17584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/19/2023] [Accepted: 09/28/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND The burden of transfusion-transmitted infections among blood recipients remains low due to extensive pre- and post-donation screening. However, the military has the unique challenge of providing blood in austere environments with limited testing capabilities. This study evaluates the infectious etiologies of deferred blood donors at a large military blood donation center. METHODS All blood donors at the Armed Service Blood Bank Center, San Antonio, between 2017 and 2022 with positive post-donation screening for hepatitis C (HCV), hepatitis B (HBV), human immunodeficiency virus (HIV), human T-lymphotropic virus (HTLV-I/II), Zika (2018-2021), West Nile virus, Trypanosoma cruzi, Treponema pallidum, or Babesia microti (2020-2022) were evaluated. Donors were deferred based on Food and Drug Administration (FDA) guidance. RESULTS Two-hundred and thirteen (213) donors met FDA criteria for deferral. T. pallidum (n = 45, 50.3 per 100,000), HCV (n = 34, 38.0 per 100,000), and HBV (n = 19, 21.2 per 100,000) were the most common pathogens among those with both positive screening and confirmatory testing. The majority of HIV (95%), Chagas (78%), HTLV-I/II (50%) deferrals were due to indeterminate confirmatory tests following initial positive screens. The majority of deferrals for HBV were for a second occurrence of a positive screen despite negative confirmatory testing. CONCLUSION The rates of post-donation deferral for transfusion-transmissible infections were low in this military cohort. Our findings suggest that donor testing in deployed service members should focus on HBV, HCV, and T. pallidum and highlight the need for better diagnostics for HIV, Chagas, and HTLV-I/II.
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Affiliation(s)
- Somin Kwon
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Brian G Casleton
- Armed Services Blood Bank Center-San Antonio, Joint Base San Antonio-Lackland, San Antonio, Texas, USA
| | - Glorimar Z Rivera
- Armed Services Blood Bank Center-San Antonio, Joint Base San Antonio-Lackland, San Antonio, Texas, USA
| | - Melita M Gella
- Armed Services Blood Bank Center-San Antonio, Joint Base San Antonio-Lackland, San Antonio, Texas, USA
- Department of Veterans Affairs, Audie Murphy VA Hospital, San Antonio, Texas, USA
| | - Erin L Winkler
- Trainee Health Surveillance, Joint Base San Antonio-Lackland, San Antonio, Texas, USA
| | - John W Kieffer
- Trainee Health Surveillance, Joint Base San Antonio-Lackland, San Antonio, Texas, USA
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Angela B Osuna
- Trainee Health Surveillance, Joint Base San Antonio-Lackland, San Antonio, Texas, USA
| | - Theresa M Casey
- Trainee Health Surveillance, Joint Base San Antonio-Lackland, San Antonio, Texas, USA
| | - Heather C Yun
- Infectious Diseases Service, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Fort Sam Houston, Texas, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Joseph E Marcus
- Infectious Diseases Service, Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Fort Sam Houston, Texas, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Biselli R, Nisini R, Lista F, Autore A, Lastilla M, De Lorenzo G, Peragallo MS, Stroffolini T, D’Amelio R. A Historical Review of Military Medical Strategies for Fighting Infectious Diseases: From Battlefields to Global Health. Biomedicines 2022; 10:2050. [PMID: 36009598 PMCID: PMC9405556 DOI: 10.3390/biomedicines10082050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/12/2022] [Accepted: 08/13/2022] [Indexed: 11/17/2022] Open
Abstract
The environmental conditions generated by war and characterized by poverty, undernutrition, stress, difficult access to safe water and food as well as lack of environmental and personal hygiene favor the spread of many infectious diseases. Epidemic typhus, plague, malaria, cholera, typhoid fever, hepatitis, tetanus, and smallpox have nearly constantly accompanied wars, frequently deeply conditioning the outcome of battles/wars more than weapons and military strategy. At the end of the nineteenth century, with the birth of bacteriology, military medical researchers in Germany, the United Kingdom, and France were active in discovering the etiological agents of some diseases and in developing preventive vaccines. Emil von Behring, Ronald Ross and Charles Laveran, who were or served as military physicians, won the first, the second, and the seventh Nobel Prize for Physiology or Medicine for discovering passive anti-diphtheria/tetanus immunotherapy and for identifying mosquito Anopheline as a malaria vector and plasmodium as its etiological agent, respectively. Meanwhile, Major Walter Reed in the United States of America discovered the mosquito vector of yellow fever, thus paving the way for its prevention by vector control. In this work, the military relevance of some vaccine-preventable and non-vaccine-preventable infectious diseases, as well as of biological weapons, and the military contributions to their control will be described. Currently, the civil-military medical collaboration is getting closer and becoming interdependent, from research and development for the prevention of infectious diseases to disasters and emergencies management, as recently demonstrated in Ebola and Zika outbreaks and the COVID-19 pandemic, even with the high biocontainment aeromedical evacuation, in a sort of global health diplomacy.
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Affiliation(s)
- Roberto Biselli
- Ispettorato Generale della Sanità Militare, Stato Maggiore della Difesa, Via S. Stefano Rotondo 4, 00184 Roma, Italy
| | - Roberto Nisini
- Dipartimento di Malattie Infettive, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Roma, Italy
| | - Florigio Lista
- Dipartimento Scientifico, Policlinico Militare, Comando Logistico dell’Esercito, Via S. Stefano Rotondo 4, 00184 Roma, Italy
| | - Alberto Autore
- Osservatorio Epidemiologico della Difesa, Ispettorato Generale della Sanità Militare, Stato Maggiore della Difesa, Via S. Stefano Rotondo 4, 00184 Roma, Italy
| | - Marco Lastilla
- Istituto di Medicina Aerospaziale, Comando Logistico dell’Aeronautica Militare, Viale Piero Gobetti 2, 00185 Roma, Italy
| | - Giuseppe De Lorenzo
- Comando Generale dell’Arma dei Carabinieri, Dipartimento per l’Organizzazione Sanitaria e Veterinaria, Viale Romania 45, 00197 Roma, Italy
| | - Mario Stefano Peragallo
- Centro Studi e Ricerche di Sanità e Veterinaria, Comando Logistico dell’Esercito, Via S. Stefano Rotondo 4, 00184 Roma, Italy
| | - Tommaso Stroffolini
- Dipartimento di Malattie Infettive e Tropicali, Policlinico Umberto I, 00161 Roma, Italy
| | - Raffaele D’Amelio
- Dipartimento di Medicina Clinica e Molecolare, Sapienza Università di Roma, Via di Grottarossa 1035-1039, 00189 Roma, Italy
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Scott PT, Cohen RL, Brett-Major DM, Hakre S, Malia JA, Okulicz JF, Beckett CG, Blaylock JM, Forgione MA, Harrison SA, Murray CK, Rentas FJ, Fahie RL, Armstrong AW, Hayat AM, Pacha LA, Dawson P, Blackwell B, Eick-Cost AA, Maktabi HH, Michael NL, Jagodzinski LL, Cersovsky SB, Peel SA. Hepatitis B seroprevalence in the U.S. military and its impact on potential screening strategies. Mil Med 2020; 185:e1654-e1661. [PMID: 32648931 PMCID: PMC7526854 DOI: 10.1093/milmed/usaa131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 11/05/2019] [Accepted: 05/06/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Knowledge of the contemporary epidemiology of hepatitis B virus (HBV) infection among military personnel can inform potential Department of Defense (DoD) screening policy and infection and disease control strategies. MATERIALS AND METHODS HBV infection status at accession and following deployment was determined by evaluating reposed serum from 10,000 service members recently deployed to combat operations in Iraq and Afghanistan in the period from 2007 to 2010. A cost model was developed from the perspective of the Department of Defense for a program to integrate HBV infection screening of applicants for military service into the existing screening program of screening new accessions for vaccine-preventable infections. RESULTS The prevalence of chronic HBV infection at accession was 2.3/1,000 (95% CI: 1.4, 3.2); most cases (16/21, 76%) identified after deployment were present at accession. There were 110 military service-related HBV infections identified. Screening accessions who are identified as HBV susceptible with HBV surface antigen followed by HBV surface antigen neutralization for confirmation offered no cost advantage over not screening and resulted in a net annual increase in cost of $5.78 million. However, screening would exclude as many as 514 HBV cases each year from accession. CONCLUSIONS Screening for HBV infection at service entry would potentially reduce chronic HBV infection in the force, decrease the threat of transfusion-transmitted HBV infection in the battlefield blood supply, and lead to earlier diagnosis and linkage to care; however, applicant screening is not cost saving. Service-related incident infections indicate a durable threat, the need for improved laboratory-based surveillance tools, and mandate review of immunization policy and practice.
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Affiliation(s)
- Paul T Scott
- Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
| | - Robert L Cohen
- U.S. Army Public Health Center, 5158 Black Hawk Road, Gunpowder, MD 21010
- United States Agency for International Development, Ronald Reagan Building, Washington, DC 20523-1000
| | - David M Brett-Major
- Department of Epidemiology University of Nebraska Medical Center College of Public Health 984395 Nebraska Medical Center Omaha NE 68198-4395
| | - Shilpa Hakre
- Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, 6720A Rockledge Drive, Bethesda, MD 20817
| | - Jennifer A Malia
- Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
| | - Jason F Okulicz
- San Antonio Military Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - Charmagne G Beckett
- Navy Bloodborne Infection Management Center, 8901 Wisconsin Avenue, Bethesda, MD 20889
| | - Jason M Blaylock
- Infectious Disease Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889
| | - Michael A Forgione
- San Antonio Military Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - Stephen A Harrison
- San Antonio Military Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - Clinton K Murray
- San Antonio Military Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234
| | - Francisco J Rentas
- Armed Services Blood Program Office, 7700 Arlington Boulevard, Falls Church, VA 22042-5143
| | - Roland L Fahie
- Armed Services Blood Program Office, 7700 Arlington Boulevard, Falls Church, VA 22042-5143
| | - Adam W Armstrong
- Naval Medical Research Center, 8901 Wisconsin Ave, Bethesda, MD 20889
| | - Aatif M Hayat
- U.S. Army Public Health Center, 5158 Black Hawk Road, Gunpowder, MD 21010
| | - Laura A Pacha
- U.S. Army Public Health Center, 5158 Black Hawk Road, Gunpowder, MD 21010
- Regional Health Command, Central, 2899 Schofield Road, San Antonio, TX 78234
| | - Peter Dawson
- The Emmes Corporation, 401 N Washington, Rockville, MD 20850
| | - Beth Blackwell
- The Emmes Corporation, 401 N Washington, Rockville, MD 20850
| | - Angelia A Eick-Cost
- Defense Health Agency, Armed Forces Health Surveillance Branch, 11800 Tech Road, Silver Spring, MD 20904
- Cherokee Nation Technology Solutions, 10838 E Marshall Street, Tulsa, OK 74116
| | - Hala H Maktabi
- Defense Health Agency, Armed Forces Health Surveillance Branch, 11800 Tech Road, Silver Spring, MD 20904
- Office of Assistant Secretary for Policy & Planning, Washington, DC
| | - Nelson L Michael
- Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
| | - Linda L Jagodzinski
- Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
| | - Steven B Cersovsky
- U.S. Army Public Health Center, 5158 Black Hawk Road, Gunpowder, MD 21010
| | - Sheila A Peel
- Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910
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Cortesi PA, Barca R, Giudicatti G, Mossini S, Ciaccio A, Iannazzo S, Micale M, Cesana G, Mantovani LG. Systematic review: economic evaluations of HCV screening in the direct-acting antivirals era. Aliment Pharmacol Ther 2019; 49:1126-1133. [PMID: 30843268 DOI: 10.1111/apt.15201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/26/2018] [Accepted: 02/01/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND The World Health Organization estimated that 90% of the infected people need to be diagnosed and 80% need to be treated to reach the aim of hepatitis C virus (HCV) elimination by 2030. For this reason, all possible strategies to detect and treat HCV-infected people need to be carefully evaluated to implement the best one. AIM To review and synthesise the economic evaluations of HCV screening programs conducted in the era of direct-acting antiviral agents regimens. METHODS A systematic literature review was conducted until April 2018 to provide information on the costs and effectiveness of HCV screenings in direct-acting antiviral agents era. A critical assessment of the quality of economic evaluations retrieved was conducted. RESULTS The literature search identified 716 references; 17 of them assessed cost and effectiveness of screening programs and antiviral treatments in different populations: general population (n = 7), drug users (n = 5), high-risk populations (n = 4) and other populations (n = 3). The HCV screening and direct-acting antiviral agents treatment appear to be good value for money, both in general and high-risk populations, if a cost per quality adjusted life years of $50 000 is set as willingness to pay threshold. Some studies showed the value of including lower stage of fibrosis in the treatment selection criteria. CONCLUSIONS Several HCV screening strategies plus direct-acting antiviral agents treatments resulted cost-effectiveness in different populations. However, there is still need of country and population-specific evaluations within the different HCV screening and treatment strategies available, in order to assess their cost-effectiveness and sustainability and fully support an evidence-informed policy for HCV elimination.
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Affiliation(s)
- Paolo Angelo Cortesi
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | - Roberta Barca
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | - Giulia Giudicatti
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | - Sergio Mossini
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | - Antonio Ciaccio
- Unit of Gastroenterology, Department of Medicine, Hospital San Gerardo, Monza, Italy.,International Center for Digestive Health, University of Milan-Bicocca, Monza, Italy
| | - Sergio Iannazzo
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy.,SIHS Health Economics Consulting, Turin, Italy
| | - Mariangela Micale
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | - Giancarlo Cesana
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
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Greenaway C, Makarenko I, Chakra CNA, Alabdulkarim B, Christensen R, Palayew A, Tran A, Staub L, Pareek M, Meerpohl JJ, Noori T, Veldhuijzen I, Pottie K, Castelli F, Morton RL. The Effectiveness and Cost-Effectiveness of Hepatitis C Screening for Migrants in the EU/EEA: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E2013. [PMID: 30223539 PMCID: PMC6164358 DOI: 10.3390/ijerph15092013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/24/2018] [Accepted: 09/10/2018] [Indexed: 12/16/2022]
Abstract
Chronic hepatitis C (HCV) is a public health priority in the European Union/European Economic Area (EU/EEA) and is a leading cause of chronic liver disease and liver cancer. Migrants account for a disproportionate number of HCV cases in the EU/EEA (mean 14% of cases and >50% of cases in some countries). We conducted two systematic reviews (SR) to estimate the effectiveness and cost-effectiveness of HCV screening for migrants living in the EU/EEA. We found that screening tests for HCV are highly sensitive and specific. Clinical trials report direct acting antiviral (DAA) therapies are well-tolerated in a wide range of populations and cure almost all cases (>95%) and lead to an 85% lower risk of developing hepatocellular carcinoma and an 80% lower risk of all-cause mortality. At 2015 costs, DAA based regimens were only moderately cost-effective and as a result less than 30% of people with HCV had been screened and less 5% of all HCV cases had been treated in the EU/EEA in 2015. Migrants face additional barriers in linkage to care and treatment due to several patient, practitioner, and health system barriers. Although decreasing HCV costs have made treatment more accessible in the EU/EEA, HCV elimination will only be possible in the region if health systems include and treat migrants for HCV.
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Affiliation(s)
- Christina Greenaway
- Division of Infectious Diseases, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2 Canada.
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC H3T 1E2.
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC H3A 1A2, Canada.
| | - Iuliia Makarenko
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC H3T 1E2.
| | - Claire Nour Abou Chakra
- Department of Microbiology and Infectious Diseases, Université de Sherbrooke, Sherbrooke, QC J1H 5NG, Canada.
| | - Balqis Alabdulkarim
- Centre for Clinical Epidemiology of the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC H3T 1E2.
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital & Department of Rheumatology, Odense University Hospital, DK2000 Odense, Denmark.
| | - Adam Palayew
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC H3A 1A2, Canada.
| | - Anh Tran
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney 1450, Australia.
| | - Lukas Staub
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney 1450, Australia.
| | - Manish Pareek
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester LE1 7RH, UK.
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center, University of Freiburg, 79110 Freiburg, Germany.
| | - Teymur Noori
- European Centre for Disease Prevention and Control, 169 73 Solna, Sweden.
| | - Irene Veldhuijzen
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), 3720 BA Bilthoven, The Netherlands.
| | - Kevin Pottie
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, ON K1N 5C8, Canada.
- Centre for Global Health, University of Ottawa, Ottawa, ON K1N 5C8, Canada.
| | - Francesco Castelli
- Division of Infectious Diseases, University of Brescia, 255123 Brescia, Italy.
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney 1450, Australia.
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Coward S, Leggett L, Kaplan GG, Clement F. Cost-effectiveness of screening for hepatitis C virus: a systematic review of economic evaluations. BMJ Open 2016; 6:e011821. [PMID: 27601496 PMCID: PMC5020747 DOI: 10.1136/bmjopen-2016-011821] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES With the developments of near-cures for hepatitis C virus (HCV), who to screen has become a high-priority policy issue in many western countries. Cost-effectiveness of screening programmes should be one consideration when developing policy. The objective of this work is to synthesise the cost-effectiveness of HCV screening programmes. SETTING A systematic review was completed. 5 databases were searched until May 2016 (NHSEED, MEDLINE, the HTA Health Technology Assessment Database, EMBASE, EconLit). PARTICIPANTS Any study reporting an economic evaluation (any type) of screening compared with opportunistic or no screening for HCV was included. Exclusion criteria were: (1) abstracts or commentaries, (2) economic evaluations of other interventions for HCV, including blood donors screening, diagnosis tests for HCV, screening for concurrent disease or medications for treatment. PRIMARY AND SECONDARY OUTCOME MEASURES Data extraction included type of model, target population, perspective, comparators, time horizon, discount rate, clinical inputs, cost inputs and outcome. Quality was evaluated using the Consolidated Health Economic Evaluation Reporting Standards checklist. Data are summarised using narrative synthesis by population. RESULTS 2305 abstracts were identified with 52 undergoing full-text review. 30 papers met inclusion criteria addressing 7 populations: drug users (n=6), high risk (n=5), pregnant (n=4), prison (n=3), birth cohort (n=8), general population (n=5) and other (n=6). The majority (77%) of the studies were high quality. Drug users, birth cohort and high-risk populations were associated with cost-effectiveness ratios of under £30 000 per quality-adjusted-life-year (QALY). The remaining populations were associated with cost-effectiveness ratios that exceeded £30 000 per QALY. CONCLUSIONS Economic evidence for screening populations is robust. If a cost per QALY of £30 000 is considered reasonable value for money, then screening birth cohorts, drug users and high-risk populations are policy options that should be considered.
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Affiliation(s)
- Stephanie Coward
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Laura Leggett
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Gilaad G Kaplan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Fiona Clement
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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