To assess the total medical costs and productivity losses associated with the 1993 waterborne outbreak of cryptosporidiosis in Milwaukee, Wisconsin, including the average cost per person with mild, moderate, and severe illness, we conducted a retrospective cost-of-illness analysis using data from 11 hospitals in the greater Milwaukee area and epidemiologic data collected during the outbreak. The total cost of outbreak-associated illness was $96.2 million: $31.7 million in medical costs and $64.6 million in productivity losses. The average total costs for persons with mild, moderate, and severe illness were $116, $475, and $7,808, respectively. The potentially high cost of waterborne disease outbreaks should be considered in economic decisions regarding the safety of public drinking water supplies.

The application of cost-effectiveness analysis to health care has been the subject of previous reviews. We address the use of economic evaluation methods in public health, including case studies of population-level policies, e.g., environmental regulations, injury prevention, tobacco control, folic acid fortification, and blood product safety, and the public health promotion of clinical preventive services, e.g., newborn screening, cancer screening, and childhood immunizations. We review the methods used in cost-effectiveness analysis, the implications for cost-effectiveness findings, and the extent to which economic studies have influenced policy and program decisions. We discuss reasons for the relatively limited impact to date of economic evaluation in public health. Finally, we address the vexing question of how to decide which interventions are cost effective and worthy of funding. Policy makers have funded certain interventions with rather high cost-effectiveness ratios, notably nucleic acid testing for blood product safety. Cost-effectiveness estimates are a decision aid, not a decision rule. 365

BackgroundBecause lymphatic filariasis (LF) elimination efforts are hampered by a dearth of economic information about the cost of mass drug administration (MDA) programs (using either albendazole with diethylcarbamazine [DEC] or albendazole with ivermectin), a multicenter study was undertaken to determine the costs of MDA programs to interrupt transmission of infection with LF. Such results are particularly important because LF programs have the necessary diagnostic and treatment tools to eliminate the disease as a public health problem globally, and already by 2006, the Global Programme to Eliminate LF had initiated treatment programs covering over 400 million of the 1.3 billion people at risk.Methodology/Principal FindingsTo obtain annual costs to carry out the MDA strategy, researchers from seven countries developed and followed a common cost analysis protocol designed to estimate 1) the total annual cost of the LF program, 2) the average cost per person treated, and 3) the relative contributions of the endemic countries and the external partners. Costs per person treated ranged from $0.06 to $2.23. Principal reasons for the variation were 1) the age (newness) of the MDA program, 2) the use of volunteers, and 3) the size of the population treated. Substantial contributions by governments were documented – generally 60%–90% of program operation costs, excluding costs of donated medications.Conclusions/SignificanceMDA for LF elimination is comparatively inexpensive in relation to most other public health programs. Governments and communities make the predominant financial contributions to actual MDA implementation, not counting the cost of the drugs themselves. The results highlight the impact of the use of volunteers on program costs and provide specific cost data for 7 different countries that can be used as a basis both for modifying current programs and for developing new ones.

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IntroductionMore than 42 million people in the United States are food insecure. Although some health care entities are addressing food insecurity among patients because of associations with disease risk and management, little is known about the components of these initiatives.MethodsThe Systematic Screening and Assessment Method was used to conduct a landscape assessment of US health care entity–based programs that screen patients for food insecurity and connect them with food resources. A network of food insecurity researchers, experts, and practitioners identified 57 programs, 22 of which met the inclusion criteria of being health care entities that 1) screen patients for food insecurity, 2) link patients to food resources, and 3) target patients including adults aged 50 years or older (a focus of this assessment). Data on key features of each program were abstracted from documentation and telephone interviews.ResultsMost programs (n = 13) focus on patients with chronic disease, and most (n = 12) partner with food banks. Common interventions include referrals to or a list of food resources (n = 19), case managers who navigate patients to resources (n = 15), assistance with federal benefit applications (n = 14), patient education and skill building (n = 13), and distribution of fruit and vegetable vouchers redeemable at farmers markets (n = 8). Most programs (n = 14) routinely screen all patients.ConclusionThe programs reviewed use various strategies to screen patients, including older adults, for food insecurity and to connect them to food resources. Research is needed on program effectiveness in improving patient outcomes. Such evidence can be used to inform the investments of potential stakeholders, including health care entities, community organizations, and insurers.

The authors test the hypotheses that parameters of advertising sensitivity for adolescents are significant and perhaps larger than those for adults. Cigarette brand shares of advertising voice are found to be significantly related to realized market shares, with advertising sensitivity being about three times larger among teenagers than among adults. This result is robust to various analytic assumptions and converges with strategic analysis, consumer behavior theory and research, econometric metanalyses, historical research, and corporate documents. The authors argue that cigarette competition between firms is predominated by the battle of brands for market share among the young, and assertions to the contrary, without supporting evidence, should be treated with scholarly skepticism.

IntroductionThe prevalence of food insecurity and chronic health conditions among older adults is a public health concern. However, little is known about associated health care costs. We estimated the incremental health care costs of food insecurity and selected chronic health conditions among older adults, defined as adults aged 50 or older.MethodsWe analyzed 4 years of data (2011–2014) from the National Health Interview Survey and 3 years of data (2013–2015) from the Medical Expenditure Panel Survey; we used 2-part models to estimate the incremental health care costs associated with food insecurity and 9 chronic conditions (hypertension, coronary heart disease, stroke, emphysema, asthma, cancer, chronic bronchitis, arthritis, and diabetes) among older adults.ResultsApproximately 14% of older adult respondents (n = 2,150) reported being food insecure. The 3 most common chronic conditions were the same for both food-insecure and food-secure older adults: hypertension, arthritis, and diabetes. The adjusted annual incremental health care costs resulting from food insecurity among older adults were higher in the presence of hypertension, stroke, and arthritis (P ≤ .05) and in the presence of diabetes (P ≤ .10). These findings were also true for the incremental health care costs resulting from food insecurity in the absence of these specific chronic conditions.ConclusionOur findings show that food insecurity interacts with chronic conditions. We observed higher health care costs in the presence of this interaction for those who were food insecure and had poor health than for those who were food secure.

To support the global program to eliminate lymphatic filariasis (LF), well-monitored demonstration projects are important for defining the relationship between coverage and reductions in microfilaremia. We are using mass treatment with diethylcarbamazine (DEC) and albendazole in an effort to eliminate LF from Leogane, Haiti. Wuchereria bancrofti microfilaremia prevalence at baseline ranged from 0.8% to 15.9% in four sentinel sites. After three rounds of DEC-albendazole mass drug administration (MDA), both microfilaremia prevalence and intensity decreased dramatically. Mild and moderate adverse reactions after treatment were common, especially after the first MDA, but decreased after subsequent MDAs. Drug coverage for the first year was estimated to be 72%, but concerns about adverse reactions appeared to decrease drug coverage in the second MDA. As a result of community education efforts that focused on providing a greater understanding of adverse reactions, coverage increased dramatically for the third round. Program efficiency increased substantially; the costs per person treated for three rounds of MDA were 2.23 US dollars, 1.96 US dollars, and 1.30 US dollars per person, respectively. The Leogane experience highlights the importance of adapting community education and mobilization campaigns to achieve and maintain good coverage.