Anthony T. Newall

Cost-effectiveness analyses of human papillomavirus vaccination

With a human papillomavirus (HPV) vaccine soon to become available for widespread use, several studies have modelled the cost-effectiveness of vaccination. These pioneer studies are likely to be influential on the design of further analyses, and we have therefore summarised and critically reviewed the strengths and limitations of their methods and assumptions. Despite a lack of transparency in some key elements, the most influential assumptions were identified as relating to vaccine effectiveness, cervical screening, and model design. Although the studies suggest that the introduction of an HPV vaccine could be cost effective compared with current practice in the USA, there is still substantial uncertainty around key variables, and model validation seems insufficient. The desirability of vaccinating boys in addition to girls has been explored in only one study. Further refinements to model design and epidemiological variables of (type-specific) HPV disease progression, and expansions on the options for vaccine use, are required for policy making.

A systematic review of interventions in primary care to improve health literacy for chronic disease behavioral risk factors

BackgroundTo evaluate the effectiveness of interventions used in primary care to improve health literacy for change in smoking, nutrition, alcohol, physical activity and weight (SNAPW).MethodsA systematic review of intervention studies that included outcomes for health literacy and SNAPW behavioral risk behaviors implemented in primary care settings.We searched the Cochrane Library, Johanna Briggs Institute, Medline, Embase, CINAHL, Psychinfo, Web of Science, Scopus, APAIS, Australasian Medical Index, Google Scholar, Community of Science and four targeted journals (Patient Education and Counseling, Health Education and Behaviour, American Journal of Preventive Medicine and Preventive Medicine).Study inclusion criteria: Adults over 18 years; undertaken in a primary care setting within an Organisation for Economic Co-operation and Development (OECD) country; interventions with at least one measure of health literacy and promoting positive change in smoking, nutrition, alcohol, physical activity and/or weight; measure at least one outcome associated with health literacy and report a SNAPW outcome; and experimental and quasi-experimental studies, cohort, observational and controlled and non-controlled before and after studies.Papers were assessed and screened by two researchers (JT, AW) and uncertain or excluded studies were reviewed by a third researcher (MH). Data were extracted from the included studies by two researchers (JT, AW). Effectiveness studies were quality assessed. A typology of interventions was thematically derived from the studies by grouping the SNAPW interventions into six broad categories: individual motivational interviewing and counseling; group education; multiple interventions (combination of interventions); written materials; telephone coaching or counseling; and computer or web based interventions. Interventions were classified by intensity of contact with the subjects (High ≥ 8 points of contact/hours; Moderate >3 and <8; Low ≤ 3 points of contact hours) and setting (primary health, community or other).Studies were analyzed by intervention category and whether significant positive changes in SNAPW and health literacy outcomes were reported.Results52 studies were included. Many different intervention types and settings were associated with change in health literacy (73% of all studies) and change in SNAPW (75% of studies). More low intensity interventions reported significant positive outcomes for SNAPW (43% of studies) compared with high intensity interventions (33% of studies). More interventions in primary health care than the community were effective in supporting smoking cessation whereas the reverse was true for diet and physical activity interventions.ConclusionGroup and individual interventions of varying intensity in primary health care and community settings are useful in supporting sustained change in health literacy for change in behavioral risk factors. Certain aspects of risk behavior may be better handled in clinical settings while others more effectively in the community. Our findings have implications for the design of programs.

Population Seroprevalence of Human Papillomavirus Types 6, 11, 16, and 18 in Men, Women, and Children in Australia

BACKGROUND Representative population-based data on human papillomavirus (HPV) epidemiology are important for public health decision making but are difficult to obtain. Seroepidemiology is a valuable tool, although the relationship between HPV infection and seropositivity is incomplete. METHODS We obtained a large representative sample using residual diagnostic test serum samples obtained from individuals aged 0-69 years (1247 samples from male patients and 1523 samples from female patients) in Australia. Serum antibody levels to HPV types 6, 11, 16, and 18 were measured using an immunoassay. RESULTS Overall, seroprevalence of HPV types 6 and 16 was higher than seroprevalence of HPV types 11 and 18. Among female patients, peak HPV seropositivity occurred among those who were 30-39 years of age for types 6, 16, and 18 (22%, 22%, and 10.5%, respectively) and among those who were 40-49 years of age for HPV 11 (11.8%). Among male subjects, peak HPV seropositivity occurred among those who were 40-49 years of age for types 6 and 11 (15.4% and 9.1%, respectively) and among those who were 50-59 years of age for types 16 and 18 (14.3% and 8.2%, respectively). No cases of HPV seropositivity were detected in individuals <10 years of age. CONCLUSIONS Australian seroepidemiological data, showing differing age-specific patterns of HPV seropositivity in male and female patients, are likely to be generalizable to other developed countries and add to other data supporting completion of HPV vaccination before adolescence.

Influenza-related hospitalisation and death in Australians aged 50 years and older

Summary Estimating the true burden of influenza is problematic because relatively few hospitalisations or deaths are specifically coded as influenza related. Statistical regression techniques using influenza and respiratory syncytial virus surveillance data were used to estimate the number of excess hospitalisations and deaths attributable to influenza. Several International Classification of Diseases 10th Revision (ICD-10) groupings were used for both hospitalisation and mortality estimates, including influenza and pneumonia, other respiratory disorders, and circulatory disorders. For Australians aged 50–64 years, the annual excess hospitalisations attributable to influenza were 33.3 (95%CI: 23.2–43.4) per 100,000 for influenza and pneumonia and 57.6 (95%CI: 32.5–82.8) per 100,000 for other respiratory disorders. For Australians aged ≥65 years, the annual excess hospitalisations attributable to influenza were 157.4 (95%CI: 108.4–206.5) per 100,000 for influenza and pneumonia and 282.0 (95%CI: 183.7–380.3) per 100,000 for other respiratory disorders. The annual excess all-cause mortality attributable to influenza was 6.4 (95%CI: 2.6–10.2) per 100,000 and 116.4 (95%CI: 71.3–161.5) per 100,000, for Australians aged 50–64 years and those aged ≥65 years, respectively. In the age-group ≥65 years, a significant association was found between influenza activity and circulatory mortality. We conclude that influenza is responsible for a substantial amount of mortality and morbidity, over and above that which is directly diagnosed as influenza in Australians aged ≥50 years.

Acute myocardial infarction and influenza: a meta-analysis of case–control studies

Objective Acute myocardial infarction (AMI) is the leading cause of death and disability globally. There is increasing evidence from observational studies that influenza infection is associated with AMI. In patients with known coronary disease, influenza vaccination is associated with a lower risk of cardiovascular events. However, the effect of influenza vaccination on incident AMI across the entire population is less well established. Method The purpose of our systematic review of case–control studies is twofold: (1) to estimate the association between influenza infection and AMI and (2) to estimate the association between influenza vaccination and AMI. Cases included those conducted with first-time AMI or any AMI cases. Studies were appraised for quality and meta-analyses using random effects models for the influenza exposures of infection, and vaccination were conducted. Results 16 studies (8 on influenza vaccination, 10 on influenza infection and AMI) met the eligibility criteria, and were included in the review and meta-analysis. Recent influenza infection, influenza-like illness or respiratory tract infection was significantly more likely in AMI cases, with a pooled OR 2.01 (95% CI 1.47 to 2.76). Influenza vaccination was significantly associated with AMI, with a pooled OR of 0.71 (95% CI 0.56 to 0.91), equating to an estimated vaccine effectiveness of 29% (95% CI 9% to 44%) against AMI. Conclusions Our meta-analysis of case–control studies found a significant association between recent respiratory infection and AMI. The estimated vaccine effectiveness against AMI was comparable with the efficacy of currently accepted therapies for secondary prevention of AMI from clinical trial data. A large-scale randomised controlled trial is needed to provide robust evidence of the protective effect of influenza vaccination on AMI, including as primary prevention.

Influenza-related disease: The cost to the Australian healthcare system

The disease burden attributable to influenza is difficult to determine, as influenza infections are rarely virologically confirmed or recorded. Estimating the influenza-related disease burden is a prerequisite to estimate the costs. Age-specific regression models were used to estimate the number of excess hospitalisations attributable to influenza from influenza and respiratory syncytial virus surveillance data. The number of general practitioner consultations for influenza/influenza-like illness was estimated from a continuous randomly sampled national study of general practice activity. Utilising the associated costs for each of these events, a cost-of-illness study was developed from the perspective of the Australian healthcare system. There was an annual average of 310,000 general practitioner consultations for influenza/influenza-like illness and 18,400 hospitalisations attributable to influenza over the period of review. The estimated cost to the Australian healthcare system for these events was

A Randomized Clinical Trial of Three Options for N95 Respirators and Medical Masks in Health Workers

115 million annually. Influenza-related disease places a significant financial burden on the Australian healthcare system.

Influenza-attributable mortality in Australians aged more than 50 years: a comparison of different modelling approaches.

RATIONALE We compared three policy options for the use of medical masks and N95 respirators in healthcare workers (HCWs). OBJECTIVES A cluster randomized clinical trial of 1,669 hospital-based HCWs in Beijing, China in the winter of 2009-2010. METHODS Participants were randomized to medical masks, N95 respirators, or targeted use of N95 respirators while doing high-risk procedures or barrier nursing. Outcomes included clinical respiratory illness (CRI) and laboratory-confirmed respiratory pathogens in symptomatic subjects. MEASUREMENTS AND MAIN RESULTS The rate of CRI was highest in the medical mask arm (98 of 572; 17%), followed by the targeted N95 arm (61 of 516; 11.8%), and the N95 arm (42 of 581; 7.2%) (P < 0.05). Bacterial respiratory tract colonization in subjects with CRI was highest in the medical mask arm (14.7%; 84 of 572), followed by the targeted N95 arm (10.1%; 52 of 516), and lowest in the N95 arm (6.2%; 36 of 581) (P = 0.02). After adjusting for confounders, only continuous use of N95 remained significant against CRI and bacterial colonization, and for just CRI compared with targeted N95 use. Targeted N95 use was not superior to medical masks. CONCLUSIONS Continuous use of N95 respirators was more efficacious against CRI than intermittent use of N95 or medical masks. Most policies for HCWs recommend use of medical masks alone or targeted N95 respirator use. Continuous use of N95s resulted in significantly lower rates of bacterial colonization, a novel finding that points to more research on the clinical significance of bacterial infection in symptomatic HCWs. This study provides further data to inform occupational policy options for HCWs. Clinical trial registered with Australian New Zealand Clinical Trials Registry http://www.anzctr.org.au (ACTRN 12609000778280).

Which providers can bridge the health literacy gap in lifestyle risk factor modification education: a systematic review and narrative synthesis

This study aimed to compare systematically approaches to estimating influenza-attributable mortality in older Australians. Using monthly age-specific death data together with viral surveillance counts for influenza and respiratory syncytial virus, we explored two of the most frequently used methods of estimating excess influenza-attributable disease: Poisson and Serfling regression models. These approaches produced consistent age and temporal patterns in estimates of influenza-attributable mortality in older Australians but some variation in the magnitude of the disease burden. Of Australians aged >50 years, average annual estimated influenza-attributable deaths (all cause) ranged from 2314 to 3457 for the Serfling and Poisson regression models, respectively. The excess influenza-attributable disease burden was substantial under all approaches.

The Aetiological Role of Human Papillomavirus in Oesophageal Squamous Cell Carcinoma: A Meta-Analysis

BackgroundPeople with low health literacy may not have the capacity to self-manage their health and prevent the development of chronic disease through lifestyle risk factor modification. The aim of this narrative synthesis is to determine the effectiveness of primary healthcare providers in developing health literacy of patients to make SNAPW (smoking, nutrition, alcohol, physical activity and weight) lifestyle changes.MethodsStudies were identified by searching Medline, Embase, Cochrane Library, CINAHL, Joanna Briggs Institute, Psychinfo, Web of Science, Scopus, APAIS, Australian Medical Index, Community of Science and Google Scholar from 1 January 1985 to 30 April 2009. Health literacy and related concepts are poorly indexed in the databases so a list of text words were developed and tested for use. Hand searches were also conducted of four key journals. Studies published in English and included males and females aged 18 years and over with at least one SNAPW risk factor for the development of a chronic disease. The interventions had to be implemented within primary health care, with an aim to influence the health literacy of patients to make SNAPW lifestyle changes. The studies had to report an outcome measure associated with health literacy (knowledge, skills, attitudes, self efficacy, stages of change, motivation and patient activation) and SNAPW risk factor.The definition of health literacy in terms of functional, communicative and critical health literacy provided the guiding framework for the review.Results52 papers were included that described interventions to address health literacy and lifestyle risk factor modification provided by different health professionals. Most of the studies (71%, 37/52) demonstrated an improvement in health literacy, in particular interventions of a moderate to high intensity.Non medical health care providers were effective in improving health literacy. However this was confounded by intensity of intervention. Provider barriers impacted on their relationship with patients.ConclusionCapacity to provide interventions of sufficient intensity is an important condition for effective health literacy support for lifestyle change. This has implications for workforce development and the organisation of primary health care.