BackgroundNew RTS,S malaria vaccines may soon be licensed, yet its cost-effectiveness is unknown. Before the widespread introduction of RTS,S vaccines, cost-effectiveness studies are needed to help inform governments in resource-poor settings about how best to prioritize between the new vaccine and existing malaria interventions.MethodsA Markov model simulated malaria progression in a hypothetical Malawian birth cohort. Parameters were based on published data. Three strategies were compared: no intervention, vaccination at one year, and long-lasting, insecticide-treated nets (LLINs) at birth. Both health service and societal perspectives were explored. Health outcomes were measured in disability-adjusted life years (DALYs) averted and costed in 2012 US$. Incremental cost-effectiveness ratios (ICERs) were calculated and extensive sensitivity analyses were conducted. Three times GDP per capita ($1,095) per DALY averted was used for a cost-effectiveness threshold, whilst one times GDP ($365) was considered ‘very cost-effective’.ResultsFrom a societal perspective the vaccine strategy was dominant. It averted 0.11 more DALYs than LLINs and 0.372 more DALYs than the no intervention strategy per person, while costing $10.04 less than LLINs and $59.74 less than no intervention. From a health service perspective the vaccine’s ICER was $145.03 per DALY averted, and thus can be considered very cost-effective. The results were robust to changes in all variables except the vaccine and LLINs’ duration of efficacy. Vaccines remained cost-effective even at the lowest assumed efficacy levels of 49.6% (mild malaria) and 14.2% (severe malaria), and the highest price of $15. However, from a societal perspective, if the vaccine duration efficacy was set below 2.69 years or the LLIN duration of efficacy was greater than 4.24 years then LLINs became the more cost-effective strategy.ConclusionThe results showed that vaccinating Malawian children with RTS,S vaccines was very cost-effective from both a societal and a health service perspective. This result was robust to changes in most variables, including vaccine price and vaccine efficacy, but was sensitive to the duration of efficacy of the vaccine and LLINs. Given the best evidence currently available, vaccines can be considered as a very cost-effective component of Malawi’s future malaria control programmes. However, long-term follow-up studies on both interventions are needed.
In 2017, the results of a comprehensive assessment of intake for benzoic acid and its salts from nonalcoholic beverages were published for four regions (Brazil, Canada, Mexico, and the United States [U.S.]). These regions were among those identified as having the most prevalent use of benzoates in beverages globally. The results of the 2017 study did not indicate a safety concern relative to the acceptable daily intake (ADI) established for benzoates (5 mg kg body weight -1 day −1 , as benzoic acid), and supported maintaining the Codex maximum benzoate level in water-based beverages (250 mg kg −1 ). Since this time, population-specific food consumption data have been released for public use for Canada, and updated beverage consumption data have become available for the U.S. To ensure estimated intakes remain relevant, these consumption data were incorporated with previously collected brand-specific benzoate use level and market volume data for beverages. Dietary exposure to benzoates from non-alcoholic beverages was assessed using statistical modelling, either probabilistic (non-brand loyal; considering the full distribution of use levels) or deterministic (brand loyal; assuming all regular carbonated soft drinks, the brand loyal beverage type, contain benzoates at the maximum use level, and all other beverage types in which benzoates are used contain benzoates at the market-weighted average use level). In both models, estimated daily intakes at the mean and 95 th percentile were below the ADI (≤76% of the ADI) in all Canadian and U.S. population groups with a statistically reliable population size. The findings from updated Canadian and U.S. consumption data continue to support the Codex maximum benzoate level in water-based flavoured drinks at 250 mg kg −1 .
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