Dogs on the move: Estimating the risk of rabies in imported dogs in the United States, 2015-2022

BACKGROUND

Dog-mediated rabies virus variant (DMRVV), a zoonotic pathogen that causes a deadly disease in animals and humans, is present in more than 100 countries worldwide but has been eliminated from the United States since 2007. In the United States, the U.S. Centers for Disease Control and Prevention has recorded four instances of rabies in dogs imported from DMRVV-enzootic countries since 2015. However, it remains uncertain whether the incidence of DMRVV among imported dogs from these countries significantly surpasses that of domestically acquired variants among domestic U.S. dogs.

AIM

This evaluation aimed to estimate the number of dogs imported from DMRVV-enzootic countries and compare the risk of rabies between imported dogs and the U.S. domestic dog population.

MATERIALS AND METHODS

Data from the CDC's dog import permit system (implemented during 2021 under a temporary suspension of dog importation from DMRVV-enzootic countries) and U.S. Customs and Border Protection's Automated Commercial Environment system, each of which records a segment of dogs entering the U.S. from DMRVV-enzootic countries, was analysed. Additionally, we estimated the incidence rate of rabies in dogs imported from DMRVV-enzootic countries and compared it to the incidence rate within the general U.S. dog population, due to domestically acquired rabies variants, over the eight-year period (2015-2022).

RESULTS

An estimated 72,589 (range, 62,660-86,258) dogs were imported into the United States annually between 2015 and 2022 from DMRVV-enzootic countries. The estimated incidence rate of rabies was 16 times higher (range, 13.2-19.4) in dogs imported from DMRVV-enzootic countries than that estimated for domestically acquired rabies in the general U.S. dog population.

CONCLUSIONS

Preventing human exposure to dogs with DMRVV is a public health priority. The higher risk of rabies in dogs imported from DMRVV-enzootic countries supports the need for importation requirements aimed at preventing the reintroduction of DMRVV into the United States.

Cost effectiveness of preemptive school closures to mitigate pandemic influenza outbreaks of differing severity in the United States

BACKGROUND

Nonpharmaceutical interventions (NPIs) may be considered as part of national pandemic preparedness as a first line defense against influenza pandemics. Preemptive school closures (PSCs) are an NPI reserved for severe pandemics and are highly effective in slowing influenza spread but have unintended consequences.

METHODS

We used results of simulated PSC impacts for a 1957-like pandemic (i.e., an influenza pandemic with a high case fatality rate) to estimate population health impacts and quantify PSC costs at the national level using three geographical scales, four closure durations, and three dismissal decision criteria (i.e., the number of cases detected to trigger closures). At the Chicago regional level, we also used results from simulated 1957-like, 1968-like, and 2009-like pandemics. Our net estimated economic impacts resulted from educational productivity costs plus loss of income associated with providing childcare during closures after netting out productivity gains from averted influenza illness based on the number of cases and deaths for each mitigation strategy.

RESULTS

For the 1957-like, national-level model, estimated net PSC costs and averted cases ranged from $7.5 billion (2016 USD) averting 14.5 million cases for two-week, community-level closures to $97 billion averting 47 million cases for 12-week, county-level closures. We found that 2-week school-by-school PSCs had the lowest cost per discounted life-year gained compared to county-wide or school district-wide closures for both the national and Chicago regional-level analyses of all pandemics. The feasibility of spatiotemporally precise triggering is questionable for most locales. Theoretically, this would be an attractive early option to allow more time to assess transmissibility and severity of a novel influenza virus. However, we also found that county-wide PSCs of longer durations (8 to 12 weeks) could avert the most cases (31-47 million) and deaths (105,000-156,000); however, the net cost would be considerably greater ($88-$103 billion net of averted illness costs) for the national-level, 1957-like analysis.

CONCLUSIONS

We found that the net costs per death averted ($180,000-$4.2 million) for the national-level, 1957-like scenarios were generally less than the range of values recommended for regulatory impact analyses ($4.6 to 15.0 million). This suggests that the economic benefits of national-level PSC strategies could exceed the costs of these interventions during future pandemics with highly transmissible strains with high case fatality rates. In contrast, the PSC outcomes for regional models of the 1968-like and 2009-like pandemics were less likely to be cost effective; more targeted and shorter duration closures would be recommended for these pandemics.

Productivity costs associated with reactive school closures related to influenza or influenza-like illness in the United States from 2011 to 2019

INTRODUCTION

Schools close in reaction to seasonal influenza outbreaks and, on occasion, pandemic influenza. The unintended costs of reactive school closures associated with influenza or influenza-like illness (ILI) has not been studied previously. We estimated the costs of ILI-related reactive school closures in the United States over eight academic years.

METHODS

We used prospectively collected data on ILI-related reactive school closures from August 1, 2011 to June 30, 2019 to estimate the costs of the closures, which included productivity costs for parents, teachers, and non-teaching school staff. Productivity cost estimates were evaluated by multiplying the number of days for each closure by the state- and year-specific average hourly or daily wage rates for parents, teachers, and school staff. We subdivided total cost and cost per student estimates by school year, state, and urbanicity of school location.

RESULTS

The estimated productivity cost of the closures was $476 million in total during the eight years, with most (90%) of the costs occurring between 2016-2017 and 2018-2019, and in Tennessee (55%) and Kentucky (21%). Among all U.S. public schools, the annual cost per student was much higher in Tennessee ($33) and Kentucky ($19) than any other state ($2.4 in the third highest state) or the national average ($1.2). The cost per student was higher in rural areas ($2.9) or towns ($2.5) than cities ($0.6) or suburbs ($0.5). Locations with higher costs tended to have both more closures and closures with longer durations.

CONCLUSIONS

In recent years, we found significant heterogeneity in year-to-year costs of ILI-associated reactive school closures. These costs have been greatest in Tennessee and Kentucky and been elevated in rural or town areas relative to cities or suburbs. Our findings might provide evidence to support efforts to reduce the burden of seasonal influenza in these disproportionately impacted states or communities.

Costs of malaria treatment in the United States

We estimated inpatient and outpatient payments for malaria treatment in the USA. The mean cost per hospitalized patient was significantly higher than for non-hospitalized patients (e.g. $27 642 vs $1177 among patients with private insurance). Patients with severe malaria payed two to four times more than those hospitalized with uncomplicated malaria.

Cost-effectiveness of treatment strategies for populations from strongyloidiasis high-risk areas globally who will initiate corticosteroid treatment in the United States

BACKGROUND

The risk of developing strongyloidiasis hyperinfection syndrome appears to be elevated among individuals who initiate corticosteroid treatment. Presumptive treatment or treatment after screening for populations from Strongyloides stercoralis-endemic areas has been suggested before initiating corticosteroids. However, potential clinical and economic impacts of preventative strategies have not been evaluated.

METHODS

Using a decision tree model for a hypothetical cohort of 1000 individuals from S. stercoralis-endemic areas globally initiating corticosteroid treatment, we evaluated clinical and economic impacts of two interventions, 'Screen and Treat' (i.e. screening and ivermectin treatment after a positive test), and 'Presumptively Treat,' compared to current practice (i.e. 'No Intervention'). We evaluated the cost-effectiveness (net cost per death averted) of each strategy using broad ranges of pre-intervention prevalence and hospitalization rates for chronic strongyloidiasis patients initiating corticosteroid treatment.

RESULTS

For the baseline parameter estimates, 'Presumptively Treat' was cost-effective (i.e. clinically superior with cost per death averted less than a threshold of $10.6 million per life) compared to 'No Intervention' ($532 000 per death averted) or 'Screen and Treat' ($39 000 per death averted). The two parameters contributing the most uncertainty to the analysis were the hospitalization rate for individuals with chronic strongyloidiasis who initiate corticosteroids (baseline 0.166%) and prevalence of chronic strongyloidiasis (baseline 17.3%) according to a series of one-way sensitivity analyses. For hospitalization rates greater than 0.022%, 'Presumptively Treat' would remain cost-effective. Similarly, 'Presumptively Treat' remained preferred at prevalence rates of 4% or above; 'Screen and Treat' was preferred for prevalence between 2% and 4%, and 'No Intervention' was preferred for prevalence less than 2%.

CONCLUSIONS

The findings support decision-making for interventions for populations from S. stercoralis endemic areas before initiating corticosteroid treatment. Although some input parameters are highly uncertain and prevalence varies across endemic countries, 'Presumptively Treat' would likely be preferred across a range for many populations given plausible parameters.

Factors Associated with Adherence to First-Line Anti-Viral Therapy Among Commercially-Insured Patients with Chronic Hepatitis B

Background

Non-adherence to anti-viral therapy can lead to poor clinical outcomes among patients with chronic hepatitis B (CHB). We used a claims database to evaluate risk factors for non-adherence to anti-viral therapy among commercially-insured patients with CHB in the United States.

Methods

We obtained data for commercially insured adult patients with CHB prescribed entecavir or tenofovir disoproxil fumarate (TDF) in 2019. Primary outcomes were adherence to entecavir and adherence to TDF. Enrollees with a proportion of days covered (PDC) ≥ 80% were considered adherent. We presented adjusted odds ratios (AOR) from multivariate logistic regressions.

Results

Eighty-three percent (N = 640) of entecavir patients were adherent and 81% (N = 687) of TDF patients were adherent. Ninety-day supply (vs. 30-day supply; AOR=2.21; p < 0.01), mixed supply (vs. 30-day supply; AOR=2.19; p=0.04), and ever using a mail-order pharmacy (AOR=1.92, p=0.03) were associated with adherence to entecavir. Ninety-day supply (vs. 30-day supply; AOR=2.51; p < 0.01), mixed supply (vs.30-day supply; AOR=1.82; p=0.04), and use of a high-deductible health plan (vs. no high-deductible health plan; AOR= 2.29; p=0.01) were associated with adherence to TDF. Out-of-pocket spending of more than $25 per 30-day supply of TDF was associated with reduced odds of adherence to TDF (vs.<$5 per 30-day supply of TDF; AOR=0.34; p<0.01).

Conclusions

90-day and mixed duration supplies of entecavir and TDF were associated with higher fill rates as compared to 30-day supplies among commercially insured patients with CHB.

IMPACT OF OLDER ADULTS’ INTERNET USE ON THE ECONOMIC BURDEN OF INFORMAL CAREGIVING

Objectives

Digital technology enables older adults to live independently by handling health-related tasks or shopping/banking online, thus can reduce care burden. This study examines the impact of older adults’ Internet use on formal and informal care hours and its influence on estimating cost savings with active and potential Internet users.

Methods

Medicare beneficiaries ages 65 and above with functional difficulties were sampled from the 2015 National Health and Aging Trends Study (N=1,806). Care is measured by total hours for help older adults received in the past month, separated by formal and informal care. Internet use for health-related tasks and shopping/banking were measured. A survey weighted two-part model with gamma distribution was estimated. The cost savings of informal caregiving was estimated by a replacement approach.

Results

Older adults' health-related Internet use substantially reduced informal care hours by 27.7% (19.8 hours per month, p < .05), but not for formal care hours. A monthly estimated cost reduction of informal caregiving was $3,094 per an older adult with functional difficulties by applying 2020 median wage of home health aide workers. The annual savings in the cost of informal caregiving associated with older adults’ health-related Internet use is estimated to be $8.1 billion with the active users and additionally $20.1 billion with the potential health-related Internet users in the US. Discussion: Promoting health-related Internet use among older adults with functional difficulties to relieve economic burden of informal caregiving will be discussed.

The Association Between State-Issued Mask Mandates and County COVID-19 Hospitalization Rates

CONTEXT

Mask mandates are one form of nonpharmaceutical intervention that has been utilized to combat the spread of SARS-CoV2, the virus that causes COVID-19.

OBJECTIVE

This study examines the association between state-issued mask mandates and changes in county-level and hospital referral region (HRR)-level COVID-19 hospitalizations across the United States.

DESIGN

Difference-in-difference and event study models were estimated to examine the association between state-issued mask mandates and COVID-19 hospitalization outcomes.

PARTICIPANTS

All analyses were conducted with US county-level data.

INTERVENTIONS

State-issued mask mandates. County-level data on the mandates were collected from executive orders identified on state government Web sites from April 1, 2020, to December 31, 2020.

MAIN OUTCOME MEASURES

Daily county-level (and HRR-level) estimates of inpatient beds occupied by patients with confirmed or suspected COVID-19 were collected by the US Department of Health and Human Services.

RESULTS

The state issuing of mask mandates was associated with an average of 3.6 fewer daily COVID-19 hospitalizations per 100 000 people (P < .05) and a 1.2-percentage-point decrease in the percentage of county beds occupied with COVID-19 patients (P < .05) within 70 days of taking effect. Event study results suggest that this association increased the longer mask mandates were in effect. In addition, the results were robust to analyses conducted at the HRR level.

CONCLUSIONS

This study demonstrated that state-issued mask mandates were associated with reduction in COVID-19 hospitalizations across the United States during the earlier portion of the pandemic. As new variants of the virus cause spikes in COVID-19 cases, reimposing mask mandates in indoor and congested public areas, as part of a layered approach to community mitigation, may reduce the spread of COVID-19 and lessen the burden on our health care system.

Low Treatment Rates of Parasitic Diseases with Standard-of-Care Prescription Drugs in the United States, 2013-2019

To assess appropriate drug treatment of parasitic diseases in the United States, we examined the treatment rates of 11 selected parasitic infections with standard-of-care prescription drugs and compared them to the treatment rates of two more common bacterial infections (Clostridioides difficile and streptococcal pharyngitis). We used the 2013 to 2019 IBM® MarketScan® Commercial Claims and Encounters and MarketScan® Multi-State Medicaid databases, which included up to 7 years of data for approximately 88 million and 17 million individuals, respectively, to estimate treatment rates of each infection. The number of patients diagnosed with each parasitic infection varied from 57 to 5,266, and from 12 to 2,018, respectively, across the two databases. Treatment rates of 10 of 11 selected parasitic infections (range, 0-56%) were significantly less than those for streptococcal pharyngitis and Clostridioides difficile (range, 65-85%); giardiasis treatment (64%) was comparable to Clostridioides difficile (65%) in patients using Medicaid. Treatment rates for patients with opisthorchiasis, clonorchiasis, and taeniasis were less than 10%. Although we could not verify that patients had active infections because of limitations inherent to claims data, including coding errors and the inability to review patients' charts, these data suggest a need for improved treatment of parasitic infections. Further research is needed to verify the results and identify potential clinical and public health consequences.

Low Use of Standard-of-Care Antiparasitic Drugs and Increased Estimated Outpatient Payments for Treating Schistosomiasis in the United States, 2013-19

Drug utilization and payment estimates for standard-of-care treatment of schistosomiasis have not been reported previously in the United States. This study estimates the utilization of praziquantel (standard-of-care drug) among patients with schistosomiasis and outpatient payments among those who were treated with praziquantel, and investigates the factors associated with praziquantel use from 2013-19 using IBM's MarketScan® Commercial Claims and Encounters database. Claims data showed that only 21% of patients with schistosomiasis diagnoses were treated with praziquantel. The mean total drug payments per patient treated with praziquantel increased from $110 in 2013-14 to $612 in 2015-18 (P < 0.01), and use decreased. These factors, including residing in a rural area, having a documented Schistosoma haematobium infection, or having a first schistosomiasis diagnosis in 2015-16, were associated with a decreased likelihood of patients receiving standard-of-care treatment. Policy solutions to exorbitant drug pricing, and better awareness and education among healthcare providers about schistosomiasis-especially those practicing in rural areas with high immigrant populations-are needed.

Trends in Pricing and Out-of-Pocket Spending on Entecavir Among Commercially Insured Patients, 2014-2018

This cross-sectional study of health claims from patients with private insurance examines trends in the cost of entecavir prescribed for chronic hepatitis B treatment.

Increases in Anti-infective Drug Prices, Subsequent Prescribing, and Outpatient Costs

This cross-sectional study examines the association of prices for drugs to treat hookworm and pinworm with prescribing and prescription-filling behaviors and total outpatient treatment costs.

The Effect of Drug Pricing on Outpatient Payments and Treatment for Three Soil-Transmitted Helminth Infections in the United States, 2010-2017

The price of certain antiparasitic drugs (e.g., albendazole and mebendazole) has dramatically increased since 2010. The effect of these rising prices on treatment costs and use of standard of care (SOC) drugs is unknown. To measure the impact of drug prices on overall outpatient cost and quality of care, we identified outpatient visits associated with ascariasis, hookworm, and trichuriasis infections from the 2010 to 2017 MarketScan Commercial Claims and Encounters and Multi-state Medicaid databases using Truven Health MarketScan Treatment Pathways. Evaluation was limited to members with continuous enrollment in non-capitated plans 30 days prior, and 90 days following, the first diagnosis. The utilization of SOC prescriptions was considered a marker for quality of care. The impact of drug price on the outpatient expenses was measured by comparing the changes in drug and nondrug outpatient payments per patient through Welch's two sample t-tests. The total outpatient payments per patient (drug and nondrug), for the three parasitic infections, increased between 2010 and 2017. The increase was driven primarily by prescription drug payments, which increased 20.6-137.0 times, as compared with nondrug outpatient payments, which increased 0.3-2.2 times. As prices of mebendazole and albendazole increased, a shift to alternative SOC and non-SOC drug utilization was observed. Using parasitic infection treatment as a model, increases in prescription drug prices can act as the primary driver of increasing outpatient care costs. Simultaneously, there was a shift to alternative SOC, but also to non-SOC drug treatment, suggesting a decrease in quality of care.

DEPRESSION AND MEDICAL COST OF CARDIOVASCULAR DISEASES

Prevalence of cardiovascular disease (CVD), the leading cause of death worldwide, increases with age. Depression is a prevalent comorbidity with CVD. This study investigates the medical costs of CVD associated with depression using a nationally representative data, 2015 Medical Expenditure Panel Survey. Patients aged ≥18 were identified by using the International Classification of Disease, 9th Revision codes of 390-459 for CVD and 296 or 311 for depression (N=23,755). Medical costs were actual payments received by providers and classified by service types and payment sources. We estimated the medical costs for each service type and payment source using economic modelling techniques controlling for various potential confounders. Overall prevalence of depression was 11.4%; 17.0% in persons with CVD and 8.7% in persons without CVD (p<0.001). Medical cost with depression was estimated at $6900 (p<0.001) for persons with CVD and $2211 (p<0.001) for those without. Costs on depression-related prescription medicines accounted for the largest portion of medical costs among persons with CVD ($3095, p<0.001). For persons with depression but without CVD, costs on outpatient visits accounted for the largest proportion ($1179, p<0.001). Medicare payments accounted for the largest portion of the depression-associated costs at $3338 (p=0.014) for persons with CVD. Compared with persons without CVD, those with CVD demonstrated doubled rates of depression. Depression-associated medical costs among individuals with CVD were tripled what they were for persons without CVD. Increased costs associated with depression were mainly for prescribed medicines and were financed by Medicare programs for persons with CVD.

Economic Impact of the 2015 MERS Outbreak on the Republic of Korea's Tourism-Related Industries

The 2015 Middle East respiratory syndrome (MERS) outbreak in the Republic of Korea (ROK) is an example of an infectious disease outbreak initiated by international travelers to a high-income country. This study was conducted to determine the economic impact of the MERS outbreak on the tourism and travel-related service sectors, including accommodation, food and beverage, and transportation, in the ROK. We projected monthly numbers of noncitizen arrivals and indices of services for 3 travel-related service sectors during and after the MERS outbreak (June 2015 to June 2016) using seasonal autoregressive integrated moving average models. Tourism losses were estimated by multiplying the monthly differences between projected and actual numbers of noncitizen arrivals by average tourism expenditure per capita. Estimated tourism losses were allocated to travel-related service sectors to understand the distribution of losses across service sectors. The MERS outbreak was correlated with a reduction of 2.1 million noncitizen visitors corresponding with US$2.6 billion in tourism loss for the ROK. Estimated losses in the accommodation, food and beverage service, and transportation sectors associated with the decrease of noncitizen visitors were US$542 million, US$359 million, and US$106 million, respectively. The losses were demonstrated by lower than expected indices of services for the accommodation and food and beverage service sectors in June and July 2015 and for the transportation sector in June 2015. The results support previous findings that public health emergencies due to traveler-associated outbreaks of infectious diseases can cause significant losses to the broader economies of affected countries.

Vaccine delivery to newly arrived refugees and estimated costs in selected U.S. clinics, 2015

BACKGROUND

Newly arrived refugees are offered vaccinations during domestic medical examinations. Vaccination practices and costs for refugees have not been described with recent implementation of the overseas Vaccination Program for U.S.-bound Refugees (VPR). We describe refugee vaccination during the domestic medical examination and the estimated vaccination costs from the US government perspective in selected U.S. clinics.

METHODS

Site-specific vaccination processes and costs were collected from 16 clinics by refugee health partners in three states and one private academic institution. Vaccination costs were estimated from the U.S. Vaccines for Children Program and Medicaid reimbursement rates during fiscal year 2015.

RESULTS

All clinics reviewed overseas vaccination records before vaccinating, but all records were not transferred into state immunization systems. Average vaccination costs per refugee varied from $120 to $211 by site. The total average cost of domestic vaccination was 15% less among refugees arriving from VPR- vs. nonVPR-participating countries during a single domestic visit.

CONCLUSION

Our findings indicate that immunization practices and costs vary between clinics, and that clinics adapted their vaccination practices to accommodate VPR doses, yielding potential cost savings.

Economic Burden of Informal Caregiving Associated With History of Stroke and Falls Among Older Adults in the U.S

INTRODUCTION

Older adults are at high risk for stroke and falls, both of which require a large amount of informal caregiving. However, the economic burden of informal caregiving associated with stroke and fall history is not well known.

METHODS

Using the 2010 Health and Retirement Study, data on non-institutionalized adults aged ≥65 years (N=10,129) in 2015-2017 were analyzed. Two-part models were used to estimate informal caregiving hours. Based on estimates from the models using a replacement cost approach, the authors derived informal caregiving hours and costs associated with falls in the past 2 years for stroke and non-stroke persons.

RESULTS

Both the prevalence of falls overall and of falls with injuries were higher among people with stroke than those without (49.5% vs 35.1% for falls and 16.0% vs 10.3% for injurious falls, p<0.01). Stroke survivors needed more informal caregiving hours than their non-stroke counterparts, and the number of informal caregiving hours was positively associated with non-injurious falls and even more so with injurious falls. The national burden of informal caregiving (2015 U.S. dollars) associated with injurious falls amounted to $2.9 billion (95% CI=$1.1 billion, $4.7 billion) for stroke survivors (about 0.5 million people), and $6.5 billion (95% CI=$4.3 billion, $8.7 billion) for those who never had a stroke (about 3.6 million people).

CONCLUSIONS

In U.S. older adults, informal caregiving hours and costs associated with falls are substantial, especially for stroke survivors. Preventing falls and fall-related injuries, especially among stroke survivors, therefore has potential for reducing the burden of informal caregiving.

Age-specific Cost Effectiveness of Using Intravenous Recombinant Tissue Plasminogen Activator for Treating Acute Ischemic Stroke

INTRODUCTION

Studies have demonstrated that intravenous recombinant tissue plasminogen activator (IV rtPA) is a cost-effective treatment for acute ischemic stroke. Age-specific cost effectiveness has not been well examined. This study estimated age-specific incremental cost-effectiveness ratios (ICERs) of IV rtPA treatment versus no IV rtPA.

METHODS

A Markov model was developed to examine the economic impact of IV rtPA over a 20-year time horizon on four age groups (18-44, 45-64, 65-80, and ≥81 years) from the U.S. healthcare sector perspective. The model used health outcomes from a national stroke registry adjusted by parameters from previous literature and current hospitalization costs in 2013 U.S. dollars. Long-term annual costs and quality-adjusted life years (QALYs) in the years after a stroke were discounted at 3% per year. Incremental costs, incremental QALYs, and ICERs were estimated and sensitivity analyses were conducted between 2015 and 2017.

RESULTS

Use of IV rtPA gained 0.55 QALYs and cost $3,941 more than no IV rtPA for stroke patients aged ≥18 years over a 20-year time horizon. IV rtPA was a dominant strategy compared to no IV rtPA for patients aged 18-44 and 45-64 years. For patients aged 65-80 years, IV rtPA gained 0.44 QALYs and cost $4,872 more than no IV rtPA (ICER=$11,132/QALY). For patients aged ≥81 years, ICER was estimated at $48,676/QALY.

CONCLUSIONS

IV rtPA saved costs and improved health outcomes for patients aged 18-64 years and was cost effective for those aged ≥65 years. These findings support the use of IV rtPA.

A Systematic Review of Economic Evidence on Community Hypertension Interventions

CONTEXT

Effective community-based interventions are available to control hypertension. It is important to determine the economics of these interventions.

EVIDENCE ACQUISITION

Peer-reviewed studies from January 1995 through December 2015 were screened. Interventions were categorized into educational interventions, self-monitoring interventions, and screening interventions. Incremental cost-effectiveness ratios were summarized by types of interventions. The review was conducted in 2016.

EVIDENCE SYNTHESIS

Thirty-four articles were included in the review (16 from the U.S., 18 from other countries), including 25 on educational interventions, three on self-monitoring interventions, and six on screening interventions. In the U.S., five (31.3%) studies on educational interventions were cost saving. Among the studies that found the interventions cost effective, the median incremental costs were $62 (range, $40-$114) for 1-mmHg reduction in systolic blood pressure (SBP) and $13,986 (range, $6,683-$58,610) for 1 life-year gained. Outside the U.S., educational interventions cost from $0.62 (China) to $29 (Pakistan) for 1-mmHg reduction in SBP. Self-monitoring interventions, evaluated in the U.S. only, cost $727 for 1-mmHg reduction in SBP and $41,927 for 1 life-year gained. For 1 quality-adjusted life-year, screening interventions cost from $21,734 to $56,750 in the U.S., $613 to $5,637 in Australia, and $7,000 to $18,000 in China. Intervention costs to reduce 1 mmHg blood pressure or 1 quality-adjusted life-year were higher in the U.S. than in other countries.

CONCLUSIONS

Most studies found that the three types of interventions were either cost effective or cost saving. Quality of economic studies should be improved to confirm the findings.

A comparative cost analysis of the Vaccination Program for US-bound Refugees

BACKGROUND

Vaccination Program for US-bound Refugees (VPR) currently provides one or two doses of some age-specific Advisory Committee on Immunization Practices (ACIP)-recommended vaccines to US-bound refugees prior to departure.

METHODS

We quantified and compared the full vaccination costs for refugees using two scenarios: (1) the baseline of no VPR and (2) the current situation with VPR. Under the first scenario, refugees would be fully vaccinated after arrival in the United States. For the second scenario, refugees would receive one or two doses of selected vaccines before departure and complete the recommended vaccination schedule after arrival in the United States. We evaluated costs for the full vaccination schedule and for the subset of vaccines provided by VPR by four age-stratified groups; all costs were reported in 2015 US dollars. We performed one-way and probabilistic sensitivity analyses and break-even analyses to evaluate the robustness of results.

RESULTS

Vaccination costs with the VPR scenario were lower than costs of the scenario without the VPR for refugees in all examined age groups. Net cost savings per person associated with the VPR were ranged from $225.93 with estimated Refugee Medical Assistance (RMA) or Medicaid payments for domestic costs to $498.42 with estimated private sector payments. Limiting the analyses to only the vaccines included in VPR, the average costs per person were 56% less for the VPR scenario with RMA/Medicaid payments. Net cost savings with the VPR scenario were sensitive to inputs for vaccination costs, domestic vaccine coverage rates, and revaccination rates, but the VPR scenario was cost savings across a range of plausible parameter estimates.

CONCLUSIONS

VPR is a cost-saving program that would also reduce the risk of refugees arriving while infected with a vaccine preventable disease.

A literature review of cost-effectiveness of intravenous recombinant tissue plasminogen activator for treating acute ischemic stroke

Background

Intravenous recombinant tissue plasminogen activator (IV rtPA) is recommended treatment for patients with acute ischaemic stroke, but the cost-effectiveness of IV rtPA within different time windows after the onset of acute ischaemic stroke is not well reviewed.

Aims

To conduct a literature review of the cost-effectiveness studies about IV rtPA by treatment times.

Summary of review

A literature search was conducted using MEDLINE, EMBASE, CINAHL and Cochrane Library, with the keywords acute ischemic stroke, tissue plasminogen activator, cost, economic benefit, saving and incremental cost-effectiveness analysis. The review is limited to original research articles published during 1995–2016 in English-language peer-reviewed journals. We found 16 studies meeting our criteria for this review. Nine of them were cost-effectiveness studies of IV rtPA treatment within 0–3 hours after stroke onset, 2 studies within 3–4.5 hours, 3 studies within 0–4.5 hours and 2 studies within 0–6 hours. IV rtPA is a cost-saving or a cost-effectiveness strategy from most of the study results. Only one study showed incremental cost-effectiveness ratio of IV rtPA within 1 year was marginally above US$50 000 per quality-adjusted life year threshold. IV rtPA within 0–3 hours after stroke led to cost savings for lifetime or 30 years and IV rtPA within 3–4.5 hours after stroke increased costs but still was cost-effective.

Conclusions

The literature generally showed that IV rtPA was a dominant or a cost-effective strategy compared with traditional treatment for patients with acute ischaemic stroke without IV rtPA. The findings from the literature lacked generalisability because of limited data and various assumptions.

Cost analysis of measles in refugees arriving at Los Angeles International Airport from Malaysia

Background

On August 24, 2011, 31 US-bound refugees from Kuala Lumpur, Malaysia (KL) arrived in Los Angeles. One of them was diagnosed with measles post-arrival. He exposed others during a flight, and persons in the community while disembarking and seeking medical care. As a result, 9 cases of measles were identified.

Methods

We estimated costs of response to this outbreak and conducted a comparative cost analysis examining what might have happened had all US-bound refugees been vaccinated before leaving Malaysia.

Results

State-by-state costs differed and variously included vaccination, hospitalization, medical visits, and contact tracing with costs ranging from $621 to $35,115. The total of domestic and IOM Malaysia reported costs for US-bound refugees were $137,505 [range: $134,531 - $142,777 from a sensitivity analysis]. Had all US-bound refugees been vaccinated while in Malaysia, it would have cost approximately $19,646 and could have prevented 8 measles cases.

Conclusion

A vaccination program for US-bound refugees, supporting a complete vaccination for US-bound refugees, could improve refugees' health, reduce importations of vaccine-preventable diseases in the United States, and avert measles response activities and costs.

Cost of informal care for patients with cardiovascular disease or diabetes: current evidence and research challenges

PURPOSE

Patients with cardiovascular disease (CVD) or diabetes often require informal care. The burden of informal care, however, was not fully integrated into economic evaluation. We conducted a literature review to summarize the current evidence on economic burden associated with informal care imposed by CVD or diabetes.

METHODS

We searched EconLit, EMBASE, and PubMed for publications in English during the period of 1995-2015. Keywords for the search were informal care cost, costs of informal care, informal care, and economic burden. We excluded studies that (1) did not estimate monetary values, (2) examined methods or factors affecting informal care, or (3) did not address CVD or diabetes.

RESULTS

Our search identified 141 potential abstracts, and 10 of the articles met our criteria. Although little research has been conducted, studies used different methods without much consensus, estimates suffered from recall bias, and study samples were small, the costs of informal care have been found high. In 2014 US dollars, estimated additional annual costs of informal care per patient ranged from $1563 to $7532 for stroke, $860 for heart failure, and $1162 to $5082 for diabetes. The total cost of informal care ranged from $5560 to $143,033 for stoke, $12,270 to $20,319 for heart failure, and $1192 to $1321 for diabetes.

CONCLUSIONS

The costs of informal care are substantial, and excluding them from economic evaluation would underestimate economic benefits of interventions for the prevention of CVD and diabetes.

Economic burden of informal care attributable to stroke among those aged 65 years or older in China

Stroke is a leading cause of disability in China, frequently resulting in the need for informal care. No information, however, is available on costs of informal care associated with stroke, required to understand the true cost of stroke in China. Using the 2011 China Health and Retirement Longitudinal Study, we identified 4447 respondents aged ≥65 years suitable for analyses, including 184 stroke survivors. We estimated the economic burden of informal care associated with stroke using a two-part model. The monthly number of hours of informal caregiving associated with stroke was 29.2 h/stroke survivor, and the average annual cost of informal care associated with stroke was 10,612 RMB per stroke survivor. The findings stress the necessity of proper interventions to prevent stroke and will be useful for estimating the economic burden of stroke.

Abstract 139: Costs to Implement Components of Stroke Systems of Care Under the Paul Coverdell National Acute Stroke Program

Objective: During 2012-2015, the Centers for Disease Control and Prevention’s (CDC) Paul Coverdell National Acute Stroke Program (PCNASP) funded state health departments to improve the quality of stroke care in key clinical settings. The objective of this study was to assess costs for health departments and partners implementing PCNASP newly established programs.

Methods: We developed Excel-based data collection instruments to collect costs associated with implementing stroke systems of care from volunteer PCNASP-funded health departments. Nine PCNASP-funded health departments were eligible based on program characteristics, six of which agreed to participate; five focused on pre- and in-hospital stroke care, and one also included transitions to post-hospital settings. These health departments partnered with a total of 467 organizations in their six states (37 to 125 partners per state). We used an activity-based costing approach to allocate costs across primary program activities: data collection, linkage, and management; clinical guidance and expertise; quality improvement (QI); building and maintaining partnerships; program evaluation; and administration. We collected costs to the health departments paid directly by PCNASP funds, in-kind contributions from the health department, and in-kind contributions from partners. Four of the six health departments received in-kind contributions from select partners. We analyzed costs by resource category (labor; materials, travel, services, equipment; contracts, consultants; overhead) and program activities across three settings: pre-hospital, in-hospital, and post-hospital.

Results: Six health departments reported grant expenditures averaging $991,549 (ranging from $790,123 to $1,298,160) per health department over 36 months. Three of those health departments reported health department in-kind contributions averaging $374,439 (ranging from $5,805 to $1,394,097) for the same 36 months. Health departments reported greatest expenditures on labor (46%, ranging from 15% to 79%) and contracts and consultants (37%, ranging from 5% to 76%). Across program activities, health departments incurred costs for QI (37%, ranging from 17% to 60%); administration (19%, ranging from 7% to 39%); data (17%, ranging from 15% to 79%); partnerships (10%, ranging from 2% to 23%); clinical guidance (9%, ranging from 4% to 16%); and evaluation (8%, ranging from 4% to 15%). Four health departments collected in-kind contributions for 22 partners. Partners had average in-kind contributions of $373,211 (ranging from $1,040 to $1,421,729).

Conclusion: Results from this study highlight key cost drivers of implementing components of stroke systems of care. This study was the first to comprehensively document actual costs of implementing QI for stroke systems of care across multiple programs and can inform future planning efforts.

Use of intravenous tissue plasminogen activator and hospital costs for patients with acute ischaemic stroke aged 18-64 years in the USA

Introduction

Intravenous tissue plasminogen activator (IV tPA) is a globally recommended treatment for patients with acute ischaemic stroke. We examined IV tPA use among patients aged 18–64 years with a primary diagnosis of acute ischaemic stroke in the USA and inpatient costs per hospitalisation by IV tPA use status among these patients.

Methods

Using the 2010–2013 MarketScan Commercial Claims and Encounters Inpatient Data, we identified 39 149 hospitalisations with a primary diagnosis of acute ischaemic stroke. We verified those with and without IV tPA by ICD-9 procedure code 99.10. We estimated trends in IV tPA use by applying logistic regression. The average inpatient costs per acute ischaemic stroke hospitalisation were assessed for subpopulations. We examined costs per acute ischaemic stroke hospitalisation using multivariate regression models controlling for IV tPA status, age, gender, urbanisation, geographic region, Charlson comorbidity index, length of hospital stays (LOS) and discharge status.

Results

2546 hospitalisations (6.5%) used IV tPA. IV tPA use increased over time (2010 vs 2013; OR 1.50). Average inpatient costs per acute ischaemic stroke hospitalisation were $20 331 ($31 369 for the IV tPA group, $19 563 for the non-tPA group). From multivariate analyses, higher costs per acute ischaemic stroke hospitalisation were associated with longer LOS, non-home discharge destination, and IV tPA use, which might be correlated with severity of stroke.

Conclusions

Findings suggest that IV tPA use has increased in recent years while the inpatient costs per acute ischaemic stroke hospitalisation using IV tPA are substantial. Those findings are useful in better understanding the overall economic burden of stroke, short-term cost implications of using IV tPA, and for estimating the accurate cost-effectiveness of stroke treatments.

Abstract TP286: A Literature Review of Cost-effectiveness of Intravenous Recombinant Tissue Plasminogen Activator for Treating Acute Ischemic Stroke

Introduction: Intravenous recombinant tissue plasminogen activator (IV rtPA) is recommended treatment for acute ischemic stroke patients, but the cost-effectiveness of IV rtPA within different time windows after the onset of acute ischemic stroke is not well reviewed.

Objectives: We conducted a literature review of the cost-effectiveness studies about IV rtPA.

Methods: A literature search was conducted using PubMed, MEDLINE, and EconLit, with the key words stroke, cost, economic benefit, saving, cost-effectiveness, tissue plasminogen activator, and rtPA. The review is limited to original research articles published during 1995–2014 in English-language peer-reviewed journals.

Results: We found 15 studies meeting our criteria for this review. Nine of them were cost-effectiveness studies of IV rtPA treatment within 0-3 hours after stroke onset, 2 studies within 3-4.5 hours, 3 studies within 0-4.5 hours, and 1 study within 0-6 hours. IV rtPA is a cost-saving or a cost-effectiveness strategy from most of the study results. Only one study showed incremental cost-effectiveness ratio of IV rtPA within one year was marginally above $50,000 per QALY threshold. IV rtPA within 0-3 hours after stroke led to cost savings for lifetime or 30 years, and IV rtPA within 3-4.5 hours after stroke increased costs but still was cost-effective.

Conclusions: The literature generally showed that intravenous IV rtPA was a dominant or a cost-effective strategy compared to traditional treatment for acute ischemic stroke patients without IV rtPA. The findings from the literature lacked generalizability because of limited data and various assumptions.

Hospital costs associated with atrial fibrillation for patients with ischemic stroke aged 18-64 years in the United States

BACKGROUND AND PURPOSE

Hospital costs associated with atrial fibrillation (AFib) among patients with stroke have not been well-studied, especially among people aged <65 years. We estimated the AFib-associated hospital costs in US patients aged 18 to 64 years.

METHODS

We identified hospital admissions with a primary diagnosis of ischemic stroke from the 2010 to 2012 MarketScan Commercial Claims and Encounters inpatient data sets, excluding those with capitated health insurance plans, aged <18 or >64 years, missing geographic region, hospital costs below the 1st or above 99th percentile, and having carotid intervention (n=40 082). We searched the data for AFib and analyzed the costs for nonrepeat and repeat stroke admissions separately. We estimated the AFib-associated costs using multivariate regression models controlling for age, sex, geographic region, and Charlson comorbidity index.

RESULTS

Of the 33 500 nonrepeat stroke admissions, 2407 (7.2%) had AFib. Admissions with AFib cost $4991 more than those without AFib ($23 770 versus $18 779). For the 6582 repeat stroke admissions, 397 (6.0%) had AFib. The costs were $3260 more for those with AFib than those without ($24 119 versus $20 929). After controlling for potential confounders, AFib-associated costs for nonrepeat stroke admissions were $4905, representing 20.6% of the total costs for the admissions. Both the hospital costs and the AFib-associated costs were associated with age, but not with sex. AFib-associated costs for repeat stroke admissions were not significantly higher than for non-AFib patients, except for those aged 55 to 64 years ($3537).

CONCLUSIONS

AFib increased the hospital cost of ischemic stroke substantially. Further investigation on AFib-associated costs for repeat stroke admissions is needed.

Cost of informal caregiving for patients with heart failure

BACKGROUND

Heart failure is a serious health condition that requires a significant amount of informal care. However, informal caregiving costs associated with heart failure are largely unknown.

METHODS

We used a study sample of noninstitutionalized US respondents aged ≥50 years from the 2010 HRS (n = 19,762). Heart failure cases were defined by using self-reported information. The weekly informal caregiving hours were derived by a sequence of survey questions assessing (1) whether respondents had any difficulties in activities of daily living or instrumental activities of daily living, (2) whether they had caregivers because of reported difficulties, (3) the relationship between the patient and the caregiver, (4) whether caregivers were paid, and (5) how many hours per week each informal caregiver provided help. We used a 2-part econometric model to estimate the informal caregiving hours associated with heart failure. The first part was a logit model to estimate the likelihood of using informal caregiving, and the second was a generalized linear model to estimate the amount of informal caregiving hours used among those who used informal caregiving. Replacement approach was used to estimate informal caregiving cost.

RESULTS

The 943 (3.9%) respondents who self-reported as ever being diagnosed with heart failure used about 1.6 more hours of informal caregiving per week than those who did not have heart failure (P < .001). Informal caregiving hours associated with heart failure were higher among non-Hispanic blacks (3.9 hours/week) than non-Hispanic whites (1.4 hours/week). The estimated annual informal caregiving cost attributable to heart failure was $3 billion in 2010.

CONCLUSION

The cost of informal caregiving was substantial and should be included in estimating the economic burden of heart failure. The results should help public health decision makers in understanding the economic burden of heart failure and in setting public health priorities.

Cost of informal caregiving associated with stroke among the elderly in the United States

OBJECTIVES

We estimated the informal caregiving hours and costs associated with stroke.

METHODS

We selected persons aged 65 years and older in 2006 and who were also included in the 2008 follow-up survey from the Health and Retirement Study. We adapted the case-control study design by using self-reported occurrence of an initial stroke event during 2006 and 2008 to classify persons into the stroke (case) and the nonstroke (control) groups. We compared informal caregiving hours between case and control groups in 2006 (prestroke period for case group) and in 2008 (poststroke period for case group) and estimated incremental informal caregiving hours attributable to stroke by applying a difference-in-differences technique to propensity score-matched populations. We used a replacement approach to estimate the economic value of informal caregiving.

RESULTS

The weekly incremental informal caregiving hours attributable to stroke were 8.5 hours per patient. The economic value of informal caregiving per stroke survivor was $8,211 per year, of which $4,356 (53%) was attributable to stroke. At the national level, the annual economic burden of informal caregiving associated with stroke among elderly was estimated at $14.2 billion in 2008.

CONCLUSIONS

Recent changes in public health and social support policies recognize the economic burden of informal caregiving. Our estimates reinforce the high economic burden of stroke in the United States and provide up-to-date information for policy development and decision-making.

EXAMINING THE EDUCATION GRADIENT IN CHRONIC ILLNESS

We examine the education gradient in diabetes, hypertension, and high cholesterol. We take into account diagnosed as well as undiagnosed cases, and use methods accounting for the possibility of unmeasured factors that are correlated with education and drive both the likelihood of having illness and the propensity to be diagnosed. Data come from the National Health and Nutrition Examination Survey (NHANES) 1999-2012. The education gradient in chronic disease varies by whether self-reported or objective disease measures are used. Education is negatively associated with having undiagnosed disease in some cases, but findings vary by how we define undiagnosed disease.

A literature review of indirect costs associated with stroke

BACKGROUND

Stroke is a leading cause of mortality and long-term disability. However, the indirect costs of stroke, such as productivity loss and costs of informal care, have not been well studied. To better understand this, we conducted a literature review of the indirect costs of stroke.

METHODS

A literature search using PubMed, MEDLINE, and EconLit, with the key words stroke, cerebrovascular disease, subarachnoid hemorrhage, intracerebral hemorrhage, cost-of-illness, productivity loss, indirect cost, economic burden, and informal caregiving was conducted. We identified original research articles published during 1990-2012 in English-language peer-reviewed journals. We summarized indirect costs by study type, cost categories, and study settings.

RESULTS

We found 31 original research articles that investigated the indirect cost of stroke. Six of these investigated indirect costs only; the other 25 studies were cost-of-illness studies that included indirect costs as a component. Of the 31 articles, 6 examined indirect costs in the United States, with 2 of these focused solely on indirect costs. Because of diverse methods, kinds of data, and definitions of cost used in the studies, the literature indicated a very wide range internationally in the proportion of the total cost of stroke that is represented by indirect costs (from 3% to 71%).

CONCLUSIONS

Most of the literature indicates that indirect costs account for a significant portion of the economic burden of stroke, and there is a pressing need to develop proper approaches to analyze these costs and to make better use of relevant data sources for such studies or establish new ones.

Beware of being unaware: racial/ethnic disparities in chronic illness in the USA

We study racial/ethnic disparities in awareness of chronic diseases using biomarker data from the 2006 Health and Retirement Study. We explore two alternative definitions of awareness and estimate a trivariate probit model with selection, which accounts for common, unmeasured factors underlying the following: (1) self-reporting chronic disease; (2) participating in biomarker collection; and (3) having disease, conditional on participating in biomarker collection. Our findings suggest that current estimates of racial/ethnic disparities in chronic disease are sensitive to selection, and also to the definition of disease awareness used. We find that African-Americans are less likely to be unaware of having hypertension than non-Latino whites, but the magnitude of this effect falls appreciably after we account for selection. Accounting for selection, we find that African-Americans and Latinos are more likely to be unaware of having diabetes compared to non-Latino whites. These findings are based on a widely used definition of awareness - the likelihood of self-reporting disease among those who have disease. When we use an alternative definition of awareness, which considers an individual to be unaware if he or she actually has the disease conditional on self-reporting not having it, we find higher levels of unawareness among racial/ethnic minorities versus non-Latino whites for both hypertension and diabetes.

Racial/ethnic- and education-related disparities in the control of risk factors for cardiovascular disease among individuals with diabetes

OBJECTIVE

There is limited information on whether recent improvements in the control of cardiovascular disease (CVD) risk factors among individuals with diabetes have been concentrated in particular sociodemographic groups. This article estimates racial/ethnic- and education-related disparities and examines trends in uncontrolled CVD risk factors among adults with diabetes. The main racial/ethnic comparisons made are with African Americans versus non-Latino whites and Mexican Americans versus non-Latino whites.

RESEARCH DESIGN AND METHODS

The analysis samples include adults aged ≥20 years from the National Health and Nutrition Examination Survey (NHANES) 1988-1994 and the NHANES 1999-2008 who self-reported having diabetes (n = 1,065, NHANES 1988-1994; n = 1,872, NHANES 1999-2008). By use of logistic regression models, we examined the correlates of binary indicators measuring 1) high blood glucose, 2) high blood pressure, 3) high cholesterol, and 4) smoking.

RESULTS

Control of blood glucose, blood pressure, and cholesterol improved among individuals with diabetes between the NHANES 1988-1994 and the NHANES 1999-2008, but there was no change in smoking prevalence. In the NHANES 1999-2008, racial/ethnic minorities and individuals without some college education were more likely to have poorly controlled blood glucose compared with non-Latino whites and those with some college education. In addition, individuals with diabetes who had at least some college education were less likely to smoke and had better blood pressure control compared with individuals with diabetes without at least some college education.

CONCLUSIONS

Trends in CVD risk factors among individuals with diabetes improved over the past 2 decades, but racial/ethnic- and education-related disparities have emerged in some areas.

Association of MCP-1 and CCR2 polymorphisms with the risk of late acute rejection after renal transplantation in Korean patients

Among the factors modulating transplant rejection, chemokines and their respective receptors deserve special attention. Increased expression of monocyte chemoattractant protein-1 (MCP-1) and its corresponding receptor (chemokine receptor-2, CCR2) has been implicated in renal transplant rejection. To determine the impact of the MCP-1-2518G and CCR2-64I genotypes on renal allograft function, 167 Korean patients who underwent transplantation over a 25-year period were evaluated. Genomic DNA was genotyped using polymerase chain reaction followed by restriction fragment length polymorphism analysis. Fifty-five (32.9%) patients were homozygous for the MCP-1-2518G polymorphism. Nine (5.4%) patients were homozygous for the CCR2-64I polymorphism. None of the investigated polymorphism showed a significant shift in long-term allograft survival. However, a significant increase was noted for the risk of late acute rejection in recipients who were homozygous for the MCP-1-2518G polymorphism (OR, 2.600; 95% CI, 1.125–6.012; P = 0.022). There was also an association between the MCP-1-2518G/G genotype and the number of late acute rejection episodes (P = 0.024). Although there was no difference in the incidence of rejection among recipients stratified by the CCR2-V64I genotype, recipients with the CCR2-V64I GG genotype in combination with the MCP-1-2518G/G genotype had a significantly higher risk of acute or late acute rejection among the receptor-ligand combinations (P = 0.006, P = 0.008, respectively). The MCP-1 variant may be a marker for risk of late acute rejection in Korean patients.

Exogenous porcine viruses

Porcine organs, cells and tissues provide a viable source of transplants in humans, though there is some concern of public health risk from adaptation of swine infectious agents in humans. Limited information is available on the public health risk of many exogenous swine viruses, and reliable and rapid diagnostic tests are available for only a few of these. The ability of several porcine viruses to cause transplacental fetal infection (parvoviruses, circoviruses, and arteriviruses), emergence or recognition of several new porcine viruses during the last two decades (porcine circovirus, arterivirus, paramyxoviruses, herpesviruses, and porcine respiratory coronavirus) and the immunosuppressed state of the transplant recipients increases the xenozoonoses risk of humans to porcine viruses through transplantation. Much of this risk can be eliminated with vigilance and sustained monitoring along with a better understanding of pathogenesis and development of better diagnostic tests. In this review we present information on selected exogenous viruses, highlighting their characteristics, pathogenesis of viral infections in swine, methods for their detection, and the potential xenozoonoses risk they present. Emphasis has been given in this review to swine influenza virus, paramyxovirus (Nipah virus, Menagle virus, LaPiedad paramyxovirus, porcine paramyxovirus), arterivirus (porcine reproductive and respiratory syndrome virus) and circovirus as either they represent new swine viruses or present the greatest risk. We have also presented information on porcine parvovirus, Japanese encephalitis virus, encephalomyocarditis virus, herpesviruses (pseudorabies virus, porcine lymphotropic herpesvirus, porcine cytomegalovirus), coronaviruses (TGEV, PRCV, HEV, PEDV) and adenovirus. The potential of swine viruses to infect humans needs to be assessed in vitro and in vivo and rapid and more reliable diagnostic methods need to be developed to assure safe supply of porcine tissues and cells for xenotransplantation.