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Goranitis I, Lissauer DM, Coomarasamy A, Wilson A, Daniels J, Middleton L, Bishop J, Hewitt CA, Weeks AD, Mhango C, Mataya R, Ahmed I, Oladapo OT, Zamora J, Roberts TE. Antibiotic prophylaxis in the surgical management of miscarriage in low-income countries: a cost-effectiveness analysis of the AIMS trial. Lancet Glob Health 2019; 7:e1280-e1286. [PMID: 31402008 PMCID: PMC6695526 DOI: 10.1016/s2214-109x(19)30336-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 06/13/2019] [Accepted: 06/14/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND There is ongoing debate on the clinical benefits of antibiotic prophylaxis for reducing pelvic infection after miscarriage surgery. We aimed to study the cost-effectiveness of antibiotic prophylaxis in the surgical management of miscarriage in low-income countries. METHODS We did an incremental cost-effectiveness analysis using data from 3412 women recruited to the AIMS trial, a randomised, double-blind, placebo-controlled trial designed to evaluate the effectiveness of antibiotic prophylaxis in the surgical management of miscarriage in Malawi, Pakistan, Tanzania, and Uganda. Economic evaluation was done from a health-care-provider perspective on the basis of the outcome of cost per pelvic infection avoided within 2 weeks of surgery. Pelvic infection was broadly defined by the presence of clinical features or the clinically identified need to administer antibiotics. We used non-parametric bootstrapping and multilevel random effects models to estimate incremental mean costs and outcomes. Decision uncertainty was shown via cost-effectiveness acceptability frontiers. The AIMS trial is registered with the ISRCTN registry, number ISRCTN97143849. FINDINGS Between June 2, 2014, and April 26, 2017, 3412 women were assigned to receive either antibiotic prophylaxis (1705 [50%] of 3412) or placebo (1707 [50%] of 3412) in the AIMS trial. 158 (5%) of 3412 women developed pelvic infection within 2 weeks of surgery, of whom 68 (43%) were in the antibiotic prophylaxis group and 90 (57%) in the placebo group. There is 97-98% probability that antibiotic prophylaxis is a cost-effective intervention at expected thresholds of willingness-to-pay per additional pelvic infection avoided. In terms of post-surgery antibiotics, the antibiotic prophylaxis group was US$0·27 (95% CI -0·49 to -0·05) less expensive per woman than the placebo group. A secondary analysis, a sensitivity analysis, and all subgroup analyses supported these findings. Antibiotic prophylaxis, if implemented routinely before miscarriage surgery, could translate to an annual total cost saving of up to $1·4 million across the four participating countries and up to $8·5 million across the two regions of sub-Saharan Africa and south Asia. INTERPRETATION Antibiotic prophylaxis is more effective and less expensive than no antibiotic prophylaxis. Policy makers in various settings should be confident that antibiotic prophylaxis in miscarriage surgery is cost-effective. FUNDING UK Medical Research Council, Wellcome Trust, and the UK Department for International Development.
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Affiliation(s)
- Ilias Goranitis
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - David M Lissauer
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Arri Coomarasamy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Amie Wilson
- Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jane Daniels
- School of Health Sciences, University of Nottingham, UK
| | - Lee Middleton
- Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jonathan Bishop
- Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Catherine A Hewitt
- Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Andrew D Weeks
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Chisale Mhango
- College of Medicine, Department of Obstetrics and Gynaecology, Blantyre, Malawi
| | - Ronald Mataya
- College of Medicine, Department of Obstetrics and Gynaecology, Blantyre, Malawi
| | - Iffat Ahmed
- The Aga Khan University Hospital and Medical College Foundation, Karachi, Pakistan
| | - Olufemi T Oladapo
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Javier Zamora
- Hospital Universitario Ramón y Cajal, CIBER en Epidemiología y Salud Pública (CIBERESP) and Instituto de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Tracy E Roberts
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
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Ifland L, Bloch EM, Pitman JP. Funding blood safety in the 21st century. Transfusion 2017; 58:105-112. [PMID: 29030857 DOI: 10.1111/trf.14374] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/16/2017] [Accepted: 08/16/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Since 2000, there has been an historic increase in international development assistance, including blood safety projects. The result has been increased blood donations and infectious disease screening in many beneficiary countries. A comprehensive examination of international development assistance for blood safety has yet to be completed. STUDY DESIGN AND METHODS This report examines publicly available information, including donor agency websites and databases and data from the 2008 and 2012 World Health Organization Global Database on Blood Safety. RESULTS Between 2000 and 2015, from $602.4 million to $2.1 billion in international development assistance was allocated to blood safety programs worldwide, mostly as part of the global response to the human immunodeficiency virus/acquired immunodeficiency syndrome epidemic. The US President's Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis, and Malaria were responsible for the majority of blood safety funding, which peaked in 2010 and declined through 2015. CONCLUSION Between 2000 and 2015, countries with high burdens of human immunodeficiency virus/acquired immunodeficiency syndrome received funding and technical assistance to improve national laboratories, increase blood component production, and strengthen clinical practice. Global trends in international development assistance at large, including aid for blood safety, suggest that funding will not rebound.
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Affiliation(s)
- Luke Ifland
- One Heart World-Wide, San Francisco, California
| | - Evan M Bloch
- Division of Transfusion Medicine and Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - John P Pitman
- Institute of Science in Healthy Aging and Health Care (SHARE), University of Groningen, Groningen, the Netherlands
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Mafirakureva N, Nyoni H, Nkomo SZ, Jacob JS, Chikwereti R, Musekiwa Z, Khoza S, Mvere DA, Emmanuel JC, Postma MJ, van Hulst M. The costs of producing a unit of blood in Zimbabwe. Transfusion 2015; 56:628-36. [DOI: 10.1111/trf.13405] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 09/23/2015] [Accepted: 09/29/2015] [Indexed: 12/18/2022]
Affiliation(s)
- Nyashadzaishe Mafirakureva
- Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), Department of Pharmacy; University of Groningen; Groningen the Netherlands
- National Blood Service Zimbabwe
| | | | | | | | | | | | - Star Khoza
- Department of Clinical Pharmacology; University of Zimbabwe; Harare Zimbabwe
| | | | | | - Maarten J. Postma
- Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), Department of Pharmacy; University of Groningen; Groningen the Netherlands
- Institute of Science in Healthy Aging & healthCare (SHARE)
- Department of Epidemiology; University Medical Center Groningen (UMCG)
| | - Marinus van Hulst
- Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), Department of Pharmacy; University of Groningen; Groningen the Netherlands
- Department of Clinical Pharmacy and Toxicology; Martini Hospital; Groningen the Netherlands
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The impact of external donor support through the U.S. President's Emergency Plan for AIDS Relief on the cost of red cell concentrate in Namibia, 2004-2011. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2014; 13:240-7. [PMID: 25369616 DOI: 10.2450/2014.0122-14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 08/21/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND External assistance can rapidly strengthen health programmes in developing countries, but such funding can also create sustainability challenges. From 2004-2011, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) provided more than $ 8 million to the Blood Transfusion Service of Namibia (NAMBTS) for supplies, equipment, and staff salaries. This analysis describes the impact that support had on actual production costs and the unit prices charged for red cell concentrate (RCC) units issued to public sector hospitals. MATERIAL AND METHODS A costing system developed by NAMBTS to set public sector RCC unit prices was used to describe production costs and unit prices during the period of PEPFAR scale-up (2004-2009) and the 2 years in which PEPFAR support began to decline (2010-2011). Hypothetical production costs were estimated to illustrate differences had PEPFAR support not been available. RESULTS Between 2004-2006, NAMBTS sold 22,575 RCC units to public sector facilities. During this time, RCC unit prices exceeded per unit cost-recovery targets by between 40.3% (US$ 16.75 or N$ 109.86) and 168.3% (US$ 48.72 or N$ 333.28) per year. However, revenue surpluses dwindled between 2007 and 2011, the final year of the study period, when NAMBTS sold 20,382 RCC units to public facilities but lost US$23.31 (N$ 170.43) on each unit. DISCUSSION PEPFAR support allowed NAMBTS to leverage domestic cost-recovery revenue to rapidly increase blood collections and the distribution of RCC. However, external support kept production costs lower than they would have been without PEPFAR. If PEPFAR funds had not been available, RCC prices would have needed to increase by 20% per year to have met annual cost-recovery targets and funded the same level of investments as were made with PEPFAR support. Tracking the subsidising influence of external support can help blood services make strategic investments and plan for unit price increases as external funds are withdrawn.
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Lara AM, Kandulu J, Chisuwo L, Kashoti A, Mundy C, Bates I. Laboratory costs of a hospital-based blood transfusion service in Malawi. J Clin Pathol 2007; 60:1117-20. [PMID: 17412875 PMCID: PMC2014856 DOI: 10.1136/jcp.2006.042309] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Despite policies advocating centralised transfusion services based on voluntary donors, the hospital-based replacement donor system is widespread in sub-Saharan Africa. AIMS To evaluate the cost of all laboratory resources needed to provide a unit of safe blood in rural Malawi using the family replacement donor system METHODS Full economic costs of all laboratory tests used to screen potential donors and to perform cross-matching were documented in a prospective, observational study in Ntcheu district hospital laboratory. RESULTS 1729 potential donors were screened and 11,008 tests were performed to ensure that 1104 units of safe blood were available for transfusion. The annual cost of all transfusion-related tests (in 2005 USdollars) was USdollars 17,976, equivalent to USdollars 16.28 per unit of transfusion-ready blood. Transfusion-related tests used 53% of the laboratory's total annual expenditure of USdollars 33,608. CONCLUSIONS This is the first study to provide prospective economic costs of all laboratory tests associated with the family replacement donor system in a district hospital in Africa. Results show that despite potential economies of scale, a unit of blood from the centralised system costs about three times as much as one from the hospital-based "replacement" system. Factors affecting these relative costs are complex but are in part due to the cost of donor recruitment in centralised systems. In the replacement system the cost of donor recruitment is entirely borne by families of patients needing a blood transfusion.
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Braka F, Nanyunja M, Makumbi I, Mbabazi W, Kasasa S, Lewis RF. Hepatitis B infection among health workers in Uganda: evidence of the need for health worker protection. Vaccine 2006; 24:6930-7. [PMID: 17027122 DOI: 10.1016/j.vaccine.2006.08.029] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Revised: 08/09/2006] [Accepted: 08/17/2006] [Indexed: 11/19/2022]
Abstract
Hepatitis B exposure was assessed in 311 health workers in Uganda, a highly endemic country. Health workers were selected by random sampling from a categorized list of health workers at district level, proportionate to the population of each district. Whereas 60.1% of health workers have evidence of hepatitis B infection, with 8.7% being chronic carriers and one (0.3%) acutely infected, 36.3% are still susceptible and could benefit from vaccination. Only 5.1% reported having had at least one dose of hepatitis B vaccine and 3.5% were apparently immune through vaccination. Needle stick injuries reported by 77% of health workers were the most common mode of exposure to blood and body fluids. Trends suggested duration of service as a predictor while age and history of blood transfusion remained significant independent risk factors for hepatitis B infection. 98% of health workers are willing to be vaccinated. These results confirm the need for protection and vaccination of health workers in Uganda against hepatitis B.
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Affiliation(s)
- Fiona Braka
- World Health Organization Country Office, Kampala, Uganda.
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