The cost of tsetse control using ‘Tiny Targets’ in the sleeping sickness endemic forest area of Bonon in Côte d’Ivoire: Implications for comparing costs across different settings

Background Work to control the gambiense form of human African trypanosomiasis (gHAT), or sleeping sickness, is now directed towards ending transmission of the parasite by 2030. In order to supplement gHAT case-finding and treatment, since 2011 tsetse control has been implemented using Tiny Targets in a number of gHAT foci. As this intervention is extended to new foci, it is vital to understand the costs involved. Costs have already been analysed for the foci of Arua in Uganda and Mandoul in Chad. This paper examines the costs of controlling Glossina palpalis palpalis in the focus of Bonon in Côte d’Ivoire from 2016 to 2017. Methodology/Principal findings Some 2000 targets were placed throughout the main gHAT transmission area of 130 km2 at a density of 14.9 per km2. The average annual cost was USD 0.5 per person protected, USD 31.6 per target deployed of which 12% was the cost of the target itself, or USD 471.2 per km2 protected. Broken down by activity, 54% was for deployment and maintenance of targets, 34% for tsetse surveys/monitoring and 12% for sensitising populations. Conclusions/Significance The cost of tsetse control per km2 of the gHAT focus protected in Bonon was more expensive than in Chad or Uganda, while the cost per km2 treated, that is the area where the targets were actually deployed, was cheaper. Per person protected, the Bonon cost fell between the two, with Uganda cheaper and Chad more expensive. In Bonon, targets were deployed throughout the protected area, because G. p. palpalis was present everywhere, whereas in Chad and Uganda G. fuscipes fuscipes was found only the riverine fringing vegetation. Thus, differences between gHAT foci, in terms of tsetse ecology and human geography, impact on the cost-effectiveness of tsetse control. It also demonstrates the need to take into account both the area treated and protected alongside other impact indicators, such as the cost per person protected.

Costs of hand hygiene for all in household settings: estimating the price tag for the 46 least developed countries

IntroductionDomestic hand hygiene could prevent over 500 000 attributable deaths per year, but 6 in 10 people in least developed countries (LDCs) do not have a handwashing facility (HWF) with soap and water available at home. We estimated the economic costs of universal access to basic hand hygiene services in household settings in 46 LDCs.MethodsOur model combines quantities of households with no HWF and prices of promotion campaigns, HWFs, soap and water. For quantities, we used estimates from the WHO/UNICEF Joint Monitoring Programme. For prices, we collated data from recent impact evaluations and electronic searches. Accounting for inflation and purchasing power, we calculated costs over 2021–2030, and estimated total cost probabilistically using Monte Carlo simulation.ResultsAn estimated US$12.2–US$15.3 billion over 10 years is needed for universal hand hygiene in household settings in 46 LDCs. The average annual cost of hand hygiene promotion is US$334 million (24% of annual total), with a further US$233 million for ‘top-up’ promotion (17%). Together, these promotion costs represent US$0.47 annually per head of LDC population. The annual cost of HWFs, a purpose-built drum with tap and stand, is US$174 million (13%). The annual cost of soap is US$497 million (36%) and water US$127 million (9%).ConclusionThe annual cost of behavioural change promotion to those with no HWF represents 4.7% of median government health expenditure in LDCs, and 1% of their annual aid receipts. These costs could be covered by mobilising resources from across government and partners, and could be reduced by harnessing economies of scale and integrating hand hygiene with other behavioural change campaigns where appropriate. Innovation is required to make soap more affordable and available for the poorest households.

Infrastructure capacity planning for reducing risks of future hydrologic extremes

Floods and droughts and their associated economic, environmental, and social losses or damages are increasing in severity and frequency. Measures taken to reduce these losses or damages stemming from extreme events typically depend on how effective they are in reducing the consequences of having either too much or too little water and for longer periods of time. To identify trade-offs between the annual estimated loss or damage reduction, i.e., the benefits, however measured, and the average annual cost of various damage reduction measures, one can perform risk–cost analyses. Because of climate change, the likelihoods of future hydrologic extremes are both changing and uncertain. Also uncertain are any estimates of future damages that would occur given any specific extreme event. In addition, one cannot be certain of the future costs or benefits of damage reduction measures. This paper outlines a range of practical approaches for identifying these trade-offs, taking into account the uncertainties associated with future damages resulting from any specific flood or drought event, the changing uncertainties of future flood and drought events, and the uncertainty of future damage mitigation costs.

Economic losses due to clinical lameness in Kosovo dairy cattle

The health of dairy cows is an important factor affecting the profitability of dairy farms worldwide, and lameness is regarded as one of the most costly dairy cattle diseases. The aim of this study was to estimate the economic cost of cow lameness among Kosovo dairy farms. Data collected from 56 dairy farms were analysed with a farm-level stochastic (Monte Carlo) simulation model to estimate the cost of lameness. Lameness-associated sources of economic loss examined within the model included: reduced milk production, treatment cost, discarded milk, reduced cow body weight, and premature culling. Results showed that prevalence of lameness among cows on Kosovo dairy farms ranged from 17% to 39%. The average annual cost of lameness was estimated at €338.57 per farm (or €46.25 per cow). Reduced milk production was the largest financial contribution to the cost of lameness (45% of total economic loss) followed by premature culling (31% of total economic loss). Discarded milk, reduced cow body weight, and cost of treatment each contributed approximately 8% to the total economic loss. These findings indicate that dairy farmers need to be more cognizant of the financial losses associated with lameness and should be encouraged to implement management strategies to reduce lameness as a means of enhancing farm profitability.

IBD Disability Index Is Associated With Both Direct and Indirect Costs of Inflammatory Bowel Disease

Introduction We aimed to determine both direct (medical) and indirect (lost wages) costs of IBD and the association between the degree of IBD-related disability and extent of IBD-related costs. Methods Persons age 18-65 from the population-based University of Manitoba IBD Research Registry completed a survey including the IBD Disability Index (IBDDI) and questions related to employment, missed work (absenteeism), and reduced productivity at work (presenteeism). Administrative health data including surgeries, hospitalizations, physician claims, and prescriptions were linked to the survey and assessed. To calculate annual wage loss, number of days of missed work was multiplied by the average wage in Manitoba for the given occupation per Statistics Canada. Costs were adjusted to 2016-17 Canadian dollars. Using descriptive and regression analysis, we explored the association between IBDDI and annual direct and indirect costs associated with IBD. Results Average annual medical costs rose from $1918 among those with IBDDI 0-4 to $9,993 among those with IBDDI 80-86. Average annual cost of lost work rose from $0 among those with IBDDI 0-4 to $30,101 among those with IBDDI 80-86. Using linear regression, each additional unit of IBDDI was associated with an increase of $77 in annual medical cost (95% CI, $52-102; P < .001) and an increase of $341 in annual cost of lost wages (95% CI, $288-395; P < .001). Conclusions Costs related to IBD are significantly associated with the degree of IBD-related disability. Among the approximate 30% of the IBD population with IBDDI scores ≥40, the indirect costs of absenteeism and presenteeism accounts for ~75% of the total IBD-related costs.

The Cost of Brine Dilution in the Desalination Plants of Alicante

To reduce the environmental impact of desalination plants, a good dilution of the brine is needed. Brine dilution may be carried out using diffusers, by mixing the concentrate with other effluents, or with seawater bypassing. Seawater bypassing increases the energy consumption of the plant but, thus far, this energy consumption has not been estimated. The environmental impact statement (EIS) of desalination plants in Alicante establishes a system of seawater bypassing for diluting brine and protecting the Posidonia oceanica seagrass meadows. The aim of this paper is to quantify the energy consumption of brine dilution, which was necessary for meeting the environmental requirements from 2012 to 2018. During the research period, the plants’ operation was variable, as it depended on the supply needs. The results indicate that the energy consumption of the dilution systems fluctuated between 2,135,315 kWh in 2012 and 685,988 kWh in 2013, with an average consumption of 1,205,952 kWh for the selected period. The energy cost in 2012 was EUR 179,556, while that for 2013 was EUR 60,787, with an average annual cost of EUR 91,690. This interannual variability is due to the difference in the production values of the plants and in the dilution ratio, which oscillated between 2.5 and 7.5 seawater:brine. In addition, the dilution showed an additional cost of the energy consumed by the desalination plants of around 1.7% on average. However, it also allowed the fulfillment of the established requirements in the EIS and the protection of the Posidonia oceanica seagrass from the discharge of the desalination plants.

Costs of hand hygiene for all in household settings - estimating the price tag for the 46 least developed countries

Introduction: Domestic hand hygiene could prevent over 500,000 attributable deaths per year, but 6 in 10 people in least developed countries (LDCs) do not have a handwashing facility with soap and water available at home. We estimated the economic costs of universal access to basic hand hygiene services in household settings in 46 LDCs. Methods: Our model combines quantities of households with no handwashing facility (HWF) and prices of promotion campaigns, HWFs, soap, and water. For quantities, we used estimates from the WHO/UNICEF Joint Monitoring Programme. For prices, we collated data from recent impact evaluations and electronic searches. Accounting for inflation and purchasing power, we calculated costs over 2021-2030, and estimated total cost probabilistically using Monte Carlo simulation. Results: An estimated US$ 12.2 - 15.3 billion over 10 years is needed for universal hand hygiene in household settings in 46 LDCs. The average annual cost of hand hygiene promotion is $334 million (24% of annual total), with a further $233 million for "top-up" promotion (17%). Together, these promotion costs represent $0.47 annually per head of LDC population. The annual cost of HWFs, a purpose-built drum with tap and stand, is $174 million (13%). The annual cost of soap is $497 million (36%), and water $127 million (9%). Conclusion: The annual cost of behaviour change promotion to those with no handwashing facility represents 4.7% of median government health expenditure in LDCs, and 1% of their annual aid receipts. These costs could be covered by mobilising resources from across government and partners, and could be reduced by harnessing economies of scale and integrating hand hygiene with other behaviour change campaigns where appropriate. Innovation is required to make soap more affordable and available for the poorest households.

Economic costs of biological invasions in the United States

The United States has thousands of invasive species, representing a sizable, but unknown burden to the national economy. Given the potential economic repercussions of invasive species, quantifying these costs is of paramount importance both for national economies and invasion management. Here, we used a novel global database of invasion costs (InvaCost) to quantify the overall costs of invasive species in the United States across spatiotemporal, taxonomic, and socioeconomic scales. From 1960 to 2020, reported invasion costs totaled $4.52 trillion (USD 2017). Considering only observed, highly reliable costs, this total cost reached $1.22 trillion with an average annual cost of $19.94 billion/year. These costs increased from $2.00 billion annually between 1960-1969 to $21.08 billion annually between 2010-2020. Most costs (73%) were related to resource damages and losses ($896.22 billion), as opposed to management expenditures ($46.54 billion). Moreover, the majority of costs were reported from invaders from terrestrial habitats ($643.51 billion, 53%) and agriculture was the most impacted sector ($509.55 billion). From a taxonomic perspective, mammals ($234.71 billion) and insects ($126.42 billion) were the taxonomic groups responsible for the greatest costs. Considering the apparent rising costs of invasions, coupled with increasing numbers of invasive species and the current lack of cost information for most known invaders, our findings provide critical information for policymakers and managers.

OP0238 DRUG COST FOR BIOLOGIC AND TARGETED SYNTHETIC DMARDS FOR RHEUMATOID ARTHRITIS PATIENTS IN NORWAY FROM 2010 TO 2019 - A COUNTRY WITH A NATIONAL TENDER SYSTEM FOR DRUG PRESCRIPTION

Background:Biologic and Target Synthetic disease-modifying antirheumatic drugs (BTSs) have caused a paradigm shift in the treatment of patients with inflammatory joint disorders, e.g., rheumatoid arthritis (RA), where remission is now attainable [1]. The high cost of BTSs has caused restrictions on use and prescription, contributing to inequality of care worldwide [2]. An annual tender system was introduced in 2008 in Norway to reduce the costs of these drugs [3].Objectives:Explore changes in drug costs for BTSs for RA patients treated at Norwegian rheumatology outpatient clinics between 2010 and 2019.Methods:The project BioRheuma (BIOlogic treatment of patients suffering from inflammatory RHEUMAtic disorders in Norway) aimed to monitor patients treated with BTSs while using a designed computer program. Anonymized data files from the ten participating centers were merged and analyzed (EXCEL and SPSS). For each year in the ten-year period, the annual total cost for BTSs and mean BTS cost for treatment of one patient was calculated for all current BTSs users, for all those who started BTSs, and for patients starting naïve to BTSs. The cost was calculated based on price offers given at the annual tender process for the different years.Results:The number of registered RA patients in the databases increased from 4909 in 2010 to 9335 in 2019. Simultaneously, the number of patients treated with BTSs increased from 1959 (39.9%) in 2010 to 4209 (45.1%) in 2019. The total treatment expenditure of these BTS treated patients was lowest in 2010 with 226 million Norwegian Kroner (NOK), highest in 2014 (350 million NOK) treating 3448 patients, and second-lowest in 2019 (255 million NOK).The number of BTSs used for each year (Figure 1) is shown for all current users, all who started new BTSs treatment, and those starting BTSs naïve to BTSs. The same figure also reports the average cost of treating one RA patient with BTSs in these three groups. For the current users of BTSs, when the number of treated patients during follow-up doubled, the mean cost to treat one patient with BTSs was reduced by approximately 50% (decreasing from 115497 NOK in 2010 to 60701 NOK in 2019). The number of patients starting on BTSs approximately doubled, while keeping a steady small increase for the naïve patients to BTSs (382 in 2010 to 405 in 2019). The average starting treatment cost decreased from 114549 NOK in 2010 to 37384 NOK in 2019, and from 114987 NOK in 2010 to 28249 NOK in 2019, for patients starting on BTSs and for patients naïve to BTSs, respectively.Figure 1.A ten-year overview of treating RA patient with BTSsConclusion:Our data shows that the average annual costs of treating a Norwegian RA patient on a current BTS, with a national tender system, were reduced by approximately 50% over the ten years 2010-19. For patients starting on a BTS, the average annual cost was reduced by approximately 75%. The consequence for the payers is that treatment can be offered at a lower price, and thus costly drugs may become more available for patients. We believe that mechanisms like the Norwegian tender system enforced upon the commercial pharmaceutical market improve competition and increase availability and use of costly drugs.References:[1]Smolen JS, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020;79;685-99.[2]Bergstra SA, et al. Inequity in access to bDMARD care and how it influences disease outcomes across countries worldwide: results from the METEOR-registry. Ann Rheum Dis 2018;77:1413–20.[3]Norwegian Hospital Procurement. (Jan 2021). Available from: https://sykehusinnkjop.no.Acknowledgements:To all members of the BioRheuma projectDisclosure of Interests:None declared

P019 Audit of prostanoid use in severe Raynaud’s and adherence to treatment of digital ulcers in patients with SSc NHSE pathway: commissioning policy cost analysis and alternative therapeutic pathway proposed

Background/Aims Severe Raynaud’s phenomenon (RP) can lead to digital ulcers (DU), ischaemia, infection and gangrene. In 2015, NHS England published a commissioning policy enabling the use of bosentan for digital ulceration in SSc in patients refractory to intravenous 6-8 weekly prostanoid in combination with sildenafil following standard therapy (including calcium channel blockers (CCB), ACE inhibitors, losartan and fluoxetine). Bosentan is licensed to prevent new DUs in SSc. Specialist MDT ratification and Blueteq registration is required. RCTs showed bosentan reduced the formation of new DU by 30-50% in at risk individuals. It is a well-tolerated drug. It is now off-patent so its cost has reduced from £22,000 to £650 per year. Aim To audit current departmental practice in patients receiving prostanoid (epoprostenol) for severe RP from any cause and check adherence to the patient pathway for treatment escalation prior to prostanoid therapy. To determine approximate costs of alternative therapeutic approaches. Methods We retrospectively audited patients attending our day unit for epoprostenol infusions over a 12-month period between 2018 and 2019. Using our centre’s admissions database and electronic patient records, we identified which oral medications patients were currently co-prescribed or had previously trialled. Using pharmacy data and tariff costings, we calculated the cost of epoprostenol infusions and oral medications with blood monitoring. Results Between 2018 and 2019, 73 patients attended for epoprostenol infusions: 31 SSc, 25 RP, 17 other diagnoses (mixed/undifferentiated CTD, SLE, vasculitis). The mean number of epoprostenol infusions per patient per year was 5.92 days (range 1-25). The percentage of patients who had first been trialled on the following medications include: CCB 77.4%, ACEi/ARB 41.1%, fluoxetine 9.59%, sildenafil 87.1% and tadalafil 25.8%. In the SSc group 22.6% had also trialled bosentan. Only 2 SSc patients (6.45%) had trialled all of the drugs on the pathway prior to prostanoid reflecting the relative lack of efficacy of some first line therapies. The departmental tariff per prostanoid infusion is £450, resulting in an estimated average annual cost of £2700 per patient. The annual cost of supplying bosentan 125mg twice daily plus blood monitoring for the first year is approximately £1350. Conclusion Epoprostenol is used in our unit for patients with severe RP from a range of conditions. Sildenafil and CCB have been trialled in the majority of our patients prior to escalation. Only a minority of patients have received bosentan according to current guidelines and licensing. Given the reduction in cost, combined with the importance of avoiding hospital admissions with COVID-19, we would suggest that bosentan could be used earlier in the treatment pathway for a broader range of indications. NHSE is revising the SSc commissioning policy. Disclosure A. Young: None. B. Griffiths: None. J. Vila: None.