BACKGROUND: The Nigeria Hypertension Control Initiative (NHCI) program, launched in 2020, integrates hypertension care into primary healthcare using the HEARTS technical package, which includes screening, health counselling, and standardized hypertension treatment protocols. This package has been piloted through NHCI in Kano and Ogun States and in the Federal Capital Territory (FCT) Abuja, as part of the Hypertension Treatment in Nigeria (HTN) project. OBJECTIVE: To assess the costs of scaling up the HEARTS hypertension control package and compare these costs with those of usual care. METHODS: Data on the costs of implementing the HEARTS program were collected from 15 purposively sampled primary health facilities in Kano, Ogun, and FCT Abuja between February and April 2024. Costs included training, medicines, provider time, and administrative expenses. We used the HEARTS costing tool, an Excel-based instrument, to collect and analyze the annual costs from a health system perspective, using an activity-based approach. RESULTS: The estimated annual cost of implementing HEARTS was USD 16 per adult primary care user (PCU), with variations across the three locations: USD 21 in Abuja, USD 11 in Kano, and USD 16 in Ogun. Average annual medication costs per patient treated under HEARTS also varied by location, amounting to USD 28 in Abuja, USD 27 in Ogun, and USD 16 in Kano. Under usual care, annual medication costs per patient were estimated at USD 32 in Kano and USD 16 in Ogun (data for Abuja were unavailable). Major cost drivers for the HEARTS package included provider time (49%) and medication (47%), compared to usual care, where medication alone accounted for 80% of costs. Implementing HEARTS requires a full-time equivalent of 0.45 doctors, 1.59 nurses, and 5.21 community health workers per 10,000 primary care users. CONCLUSIONS: In the Nigerian primary care setting, provider time costs and medication costs emerge as major considerations in scaling up hypertension services. Policy options could consider reducing follow-up visit frequency for well-controlled patients to decrease provider time costs. Additionally, medication costs may be reduced by prioritizing first-line treatments and volume-driven purchasing as program scale-up continues.

BACKGROUND: In 2020, a pilot program for hypertension control was initiated in primary care facilities in Lampang Province, Thailand. The program followed the framework of the HEARTS program for standardized hypertension treatment, but the financial costs of the program are not well understood. This study evaluates the costs of the HEARTS approach compared to usual care to inform future scale-up efforts of the program. METHODS: Cost data were collected and analyzed using the HEARTS costing tool, a Microsoft Excel-based tool that supports activity-based costing of the HEARTS program from the health system perspective. Three scenarios were considered: usual care, the HEARTS regimen using standardized hypertension treatment with single-agent pills, and a sub-scenario of the HEARTS regimen using single-pill dual-drug combination pills. Costs are estimated as annual costs from the health system perspective in all Lampang primary care facilities. RESULTS: For the usual care scenario, the HEARTS single-pill scenario, and the HEARTS combination-pill sub-scenario, the average annual medication cost per treated patient was USD 14.0 (THB 485), USD 13.8 (THB 479), and USD 14.3 (THB 497), respectively. Total program cost per primary care user was USD 13.6 (THB 472.7), THB USD 14.3 (494.5), and USD 14.4 (THB 499.9) across the three scenarios, respectively. The largest program cost driver (45-47% across the examined scenarios) was attributed to a comprehensive package of laboratory tests applied to all hypertension patients. Hypothetically, reducing test coverage from all hypertension patients (27% of primary care users) to 15% of primary care users (corresponding to the proportion of patients aged 65+) would reduce program cost per user from USD 14.3 to USD 12.0 in the HEARTS combination-pill scenario. CONCLUSIONS: Compared to usual care, HEARTS implementation costs include additional costs for staff training, which are balanced by lower medication expenditures using the HEARTS standardized regimen with single-agent pills. The HEARTS regimen using dual-drug combination pills was estimated to be slightly more costly due to the higher price of combination pills. Optimizing coverage of diagnostic tests and lowering the purchasing prices of combination-pill medicines are key areas for cost reduction in future scale-up efforts.

BACKGROUND: In 2021, the Philippines launched the Healthy Hearts demonstration project for delivering hypertension (HTN) services in seven Rural Health Units (RHUs) in District 1 of Iloilo Province, West Visayas Region. This study evaluates the provider time cost and medication cost of delivering these services under three medication procurement scenarios, projecting them to the district and province levels to inform scaling-up efforts. METHODS: A mixed-methods design was used for cost data collection, including key informant interviews (KII), focus group discussions (FGD), and secondary data sources. The HEARTS costing tool was adapted to analyze program costs per patient from the health system perspective. Three scenarios were assessed, depending on the procurement scheme of HTN medications: baseline local government procurement, pooled procurement through the Philippine Pharma Procurement Inc. (PPPI) national pooling mechanism, and private pharmacy outsourcing. We assessed annual provider labor costs and medication costs per patient for each scenario. RESULTS: The average provider cost per patient was considerably lower for patients with controlled HTN than for patients with uncontrolled HTN: USD 5 (range USD 3.4-6.1 across RHUs) vs. USD 32.9 (range USD 28.8-38.4)) due to the need for more frequent follow-up visits for the latter. Average medication costs per patient were estimated at USD 9.1 (range USD 7.2-11.5) using local procurement prices, USD 2.9 (range USD 2.3-3.7) using PPPI pooled procurement prices, and USD 23 (range USD 17.9-30.5) using private pharmacy outsourced prices. The higher medicine costs in the pharmacy outsourcing scenario were partially offset by lower provider costs (an average reduction of USD 1.5 per patient per year) due to reduced on-site dispensing time in this scenario. CONCLUSIONS: The findings from this study indicate two key opportunities for cost savings in HTN management in the Philippines' rural health units system: 1) enhancing the control of HTN, thereby reducing the need for follow-up visits and cutting down on provider time costs, and 2) utilizing pooled medication procurement mechanisms such as through the Philippine Pharma Procurement Inc. Provider time costs can also be partially reduced through outsourcing the dispensing of medications to private pharmacies, although doing so is currently associated with higher medication costs, further underscoring the utility of pooled procurement mechanisms for essential hypertension medicines.

Candida species are the predominant cause of fungal infections in patients treated in hospital, contributing substantially to morbidity and mortality. Candidaemia and other forms of invasive candidiasis primarily affect patients who are immunocompromised or critically ill. In contrast, mucocutaneous forms of candidiasis, such as oral thrush and vulvovaginal candidiasis, can occur in otherwise healthy individuals. Although mucocutaneous candidiasis is generally not life-threatening, it can cause considerable discomfort, recurrent infections, and complications, particularly in patients with underlying conditions such as diabetes or in those taking immunosuppressive therapies. The rise of difficult-to-treat Candida infections is driven by new host factors and antifungal resistance. Pathogens, such as Candida auris (Candidozyma auris) and fluconazole-resistant Candida parapsilosis, pose serious global health risks. Recent taxonomic revisions have reclassified several Candida spp, potentially causing confusion in clinical practice. Current management guidelines are limited in scope, with poor coverage of emerging pathogens and new treatment options. In this Review, we provide updated recommendations for managing Candida infections, with detailed evidence summaries available in the appendix.

BACKGROUND: In 2016, Uganda introduced services for hypertension and diabetes in selected HIV clinics. We evaluated the costs associated with scaling up these services in HIV clinics in Mbarara and Ibanda districts, Uganda. METHODS: We estimated the annual costs of providing hypertension and diabetes services using an activity-based costing approach from the health system perspective in ten randomly selected HIV clinics in Mbarara and Ibanda districts. Cost inputs included 2023 data on costs of medications, health provider time, salaries, training costs, and monitoring costs. We determined the average annual cost and medication costs for hypertension and diabetes treatment per enrolled adult patient, stratified by type of health facility. RESULTS: The total annual cost of hypertension and diabetes management services in ten selected HIV clinics was estimated to be $413,850 (range: $8,386 - 186,973). The annual average clinic-level cost per enrolled patient was estimated at $14 (range: $7 - 31). Of the total annual cost, the cost of provider time for initial and follow-up visits represented the largest cost component in 5/10 clinics (mean: 37%, range [13-58%]). In 4/10 clinics, the major cost components were the costs of medication, diagnostic tests, and related supplies (mean: 37%, range [10-75%]). The average cost per enrolled adult patient was $11 at public facilities and $21 in private not-for-profit facilities. The average medication cost per patient for hypertension was $24 (range: $7 - 97) annually; $13 at public facilities and $50 at private not-for-profit facilities. For diabetes treatment, the average annual medication cost per patient was estimated at $14 (range: $6 - 35); $11 at public facilities and $22 at private not-for-profit facilities. CONCLUSION: Adding hypertension and diabetes management to routine HIV care might be feasible based on the estimated annual cost per patient. Hypertension and diabetes treatment was more costly in private not-for-profit facility-based clinics than at public facilities. This variation was primarily driven by higher medication procurement prices at private facilities, revealing a potential area for optimizing costs through improved procurement practices.

Background: International hypertension treatment guidelines recommend initiating pharmacological treatment with combination therapy and using fixed dose single pill combinations (SPCs) to improve adherence. However, few countries have adopted combination therapy as a form of first-line treatment and SPC uptake in low- and middle-income countries is low due in part to cost and availability. Evidence on costs and cost-effectiveness is needed as health authorities consider incorporating new recommendations into national clinical practice guidelines. Methods: Over a 30-year time horizon, we used an Excel-based Markov cohort state-transition model to assess the financial costs (screening, treatment, program, and supply chain costs) and socio-economic outcomes (health outcomes, value of lives saved, productivity losses averted) of three antihypertensive treatment scenarios. A baseline scenario scaled treatment among adults age 30 plus while assuming continuation of the widespread practice of initiating treatment with monotherapy. Scenarios one and two scaled treatment while initiating patients on two antihypertensive medications, either as separate pills or as a SPC. Analysis inputs are informed by country-specific data, meta-analyses of the blood-pressure lowering of antihypertensive medications, and own-studies of medication costs. We compared costs, cost-effectiveness, and net-benefits across scenarios, and assessed uncertainty in a one-way sensitivity analysis. Findings: Using dual combination therapy (with or without SPCs) as first-line treatment would increase costs relative to current practices that largely use monotherapy. Required additional annual resources averaged as much as 3.6, 0.9, and 0.2 percent of government health expenditures in the analysis’ low-, lower-middle, and upper-middle income countries. However, across 24 countries, over the next 30 years, combination therapy with separate pills could save 430,000 more lives and combination therapy with SPCs could save 564,000 more lives compared to baseline treatment practices. Administration of two or more medications using SPCs generated higher net benefits in most countries (16/24) compared to the baseline scenario. Interpretation: First line treatment employing SPCs is likely to generate higher net benefits compared to status quo treatment practices in countries with relatively higher incomes. To improve population health, national health systems would benefit from reducing structural and other barriers to the use of combination therapy and SPCs. Funding: This journal article was supported by TEPHINET cooperative agreement number 1NU2HGH000044-01-0 funded by the USCenters for Disease Control and Prevention. © 2024 The Author(s)

OBJECTIVE: Estimate the incremental costs and benefits of scaling up hypertension care in adults in 24 select countries, using three different systolic blood pressure (SBP) treatment cut-off points-≥140, ≥150 and ≥160 mm Hg. INTERVENTION: Strengthening the hypertension care cascade compared with status quo levels, with pharmacological treatment administered at different cut-points depending on the scenario. TARGET POPULATION: Adults aged 30+ in 24 low-income and middle-income countries spanning all world regions. PERSPECTIVE: Societal. TIME HORIZON: 30 years. DISCOUNT RATE: 4%. COSTING YEAR: 2020 USD. STUDY DESIGN: DATA SOURCES: Institute for Health Metrics and Evaluation's Epi Visualisations database-country-specific cardiovascular disease (CVD) incidence, prevalence and death rates. Mean SBP and prevalence-National surveys and NCD-RisC. Treatment protocols-WHO HEARTS. Treatment impact-academic literature. Costs-national and international databases. OUTCOME MEASURES: Health outcomes-averted stroke and myocardial infarction events, deaths and disability-adjusted life-years; economic outcomes-averted health expenditures, value of averted mortality and workplace productivity losses. RESULTS OF ANALYSIS: Across 24 countries, over 30 years, incremental scale-up of hypertension care for adults with SBP≥140 mm Hg led to 2.6 million averted CVD events and 1.2 million averted deaths (7% of expected CVD deaths). 68% of benefits resulted from treating those with very high SBP (≥160 mm Hg). 10 of the 12 highest-income countries projected positive net benefits at one or more treatment cut-points, compared with 3 of the 12 lowest-income countries. Treating hypertension at SBP≥160 mm Hg maximised the net economic benefit in the lowest-income countries. LIMITATIONS: The model only included a few hypertension-attributable diseases and did not account for comorbid risk factors. Modelled scenarios assumed ambitious progress on strengthening the care cascade. CONCLUSIONS: In areas where economic considerations might play an outsized role, such as very low-income countries, prioritising treatment to populations with severe hypertension can maximise benefits net of economic costs.

Despite the high burden of hyperlipidemia and the effectiveness of treatment, evidence suggests that the accessibility of hyperlipidemia medicines can be low in many low- and middle-income countries (LMICs). The aim of this study was to identify common barriers to the accessibility of medicines for hyperlipidemia in LMICs. A multimethod analysis and multiple data sources were used to assess the accessibility and barriers of medicines for hyperlipidemia in selected LMICs. The overall median availability of statins for hyperlipidemia in public facilities was 0% and 5.4%, for originators and generics, respectively. In private facilities, median availability was 13.3% and 35.9%, for originators and generics, respectively. Statin availability was lowest in Africa and South-East Asia. Private facilities generally had higher availability than public facilities. Statins are less affordable in lower-income countries, costing around 6 days' wages per month. Originator statins are less affordable than generics in countries of all income-levels. The median cost for statin medications per month ranges from a low of $1 in Kenya to a high of $62 in Mexico, with most countries having a median monthly cost between $3.6 and $17.0. The key informant interviews suggested that accessibility to hyperlipidemia medicines in LMICs faces barriers in multiple dimensions of health systems. The availability and affordability of statins are generally low in LMICs. Several steps could be implemented to improve the accessibility of hyperlipidemia medicines, including private sector engagement, physician education, investment in technology, and enhancement of health systems.

BACKGROUND: In 2020, Ethiopia launched the Ethiopia Hypertension Control Initiative (EHCI) program to improve hypertension care using the approach described in the WHO HEARTS technical package. OBJECTIVE: To estimate the costs of implementing the HEARTS program for hypertension control and cardiovascular disease (CVD) prevention in the primary care setting in Ethiopia for adult primary care users in the catchment area of five examined facilities. STUDY DESIGN: This study entails a program cost analysis using cross-sectional primary and secondary data. METHODS: Micro-costing facility surveys were used to assess activity costs related to training, counselling, screening, lab diagnosis, medications, monitoring, and start-up costs at five selected health facilities. Cost data were obtained from primary and secondary sources, and expert opinion. Annual costs from the health system perspective were estimated using the Excel-based HEARTS costing tool under two intervention scenarios - hypertension-only control and a CVD risk management program, which addresses diabetes and hypercholesterolemia in addition to hypertension. RESULTS: The estimated cost per adult primary care user was USD 5.3 for hypertension control and USD 19.3 for integrated CVD risk management. The estimated medication cost per person treated for hypertension was USD 9.0, whereas treating diabetes and high cholesterol would cost USD 15.4 and USD 15.3 per person treated, respectively. Medications were the major cost driver, accounting for 37% of the total cost in the hypertension control program. In the CVD risk management scenario, the proportions of medication and lab diagnostics of total costs were 18% and 64%, respectively. CONCLUSIONS: The results from this study can inform planning and budgeting for HEARTS scale-up to prevent CVD across Ethiopia.

On September 1, 2022, CDC recommended an updated (bivalent) COVID-19 vaccine booster to help restore waning protection conferred by previous vaccination and broaden protection against emerging variants for persons aged ≥12 years (subsequently extended to persons aged ≥6 months).* To assess the impact of original (monovalent) COVID-19 vaccines and bivalent boosters, case and mortality rate ratios (RRs) were estimated comparing unvaccinated and vaccinated persons aged ≥12 years by overall receipt of and by time since booster vaccination (monovalent or bivalent) during Delta variant and Omicron sublineage (BA.1, BA.2, early BA.4/BA.5, and late BA.4/BA.5) predominance.(†) During the late BA.4/BA.5 period, unvaccinated persons had higher COVID-19 mortality and infection rates than persons receiving bivalent doses (mortality RR = 14.1 and infection RR = 2.8) and to a lesser extent persons vaccinated with only monovalent doses (mortality RR = 5.4 and infection RR = 2.5). Among older adults, mortality rates among unvaccinated persons were significantly higher than among those who had received a bivalent booster (65-79 years; RR = 23.7 and ≥80 years; 10.3) or a monovalent booster (65-79 years; 8.3 and ≥80 years; 4.2). In a second analysis stratified by time since booster vaccination, there was a progressive decline from the Delta period (RR = 50.7) to the early BA.4/BA.5 period (7.4) in relative COVID-19 mortality rates among unvaccinated persons compared with persons receiving who had received a monovalent booster within 2 weeks-2 months. During the early BA.4/BA.5 period, declines in relative mortality rates were observed at 6-8 (RR = 4.6), 9-11 (4.5), and ≥12 (2.5) months after receiving a monovalent booster. In contrast, bivalent boosters received during the preceding 2 weeks-2 months improved protection against death (RR = 15.2) during the late BA.4/BA.5 period. In both analyses, when compared with unvaccinated persons, persons who had received bivalent boosters were provided additional protection against death over monovalent doses or monovalent boosters. Restored protection was highest in older adults. All persons should stay up to date with COVID-19 vaccination, including receipt of a bivalent booster by eligible persons, to reduce the risk for severe COVID-19.

Generally, hypertension control programs are cost-effective, including in low- and middle-income countries, but country governments and civil society are not likely to support hypertension control programs unless value is demonstrated in terms of public health benefits, budget impact, and value-for-investment for the individual country context. The World Health Organization (WHO) and the Pan American Health Organization (PAHO) established a standard, simplified Global HEARTS approach to hypertension control, including preferred antihypertensive medicines and blood pressure measurement devices. The objective of this study is to report on health economic studies of HEARTS hypertension control package cost (especially medication costs), cost-effectiveness, and budget impact and describe mathematical models designed to translate hypertension control program data into the optimal approach to hypertension care service delivery and financing, especially in low- and middle-income countries. Early results suggest that HEARTS hypertension control interventions are either cost-saving or cost-effective, that the HEARTS package is affordable at between US$ 18-44 per person treated per year, and that antihypertensive medicines could be priced low enough to reach a global standard of an average <US$ 5 per patient per year in the public sector. This health economic evidence will make a compelling case for government ownership and financial support for national scale hypertension control programs.

OBJECTIVE: To estimate the costs of scaling up the HEARTS pilot project for hypertension management and risk-based cardiovascular disease (CVD) prevention at the full population level in the four subdistricts (upazilas) in Bangladesh. SETTINGS: Two intervention scenarios in subdistrict health complexes: hypertension management only, and risk-based integrated hypertension, diabetes, and cholesterol management. DESIGN: Data obtained during July-August 2020 from subdistrict health complexes on the cost of medications, diagnostic materials, staff salaries and other programme components. METHODS: Programme costs were assessed using the HEARTS costing tool, an Excel-based instrument to collect, track and evaluate the incremental annual costs of implementing the HEARTS programme from the health system perspective. PRIMARY AND SECONDARY OUTCOME MEASURES: Programme cost, provider time. RESULTS: The total annual cost for the hypertension control programme was estimated at US$3.2million, equivalent to US$2.8 per capita or US$8.9 per eligible patient. The largest cost share (US$1.35million; 43%) was attributed to the cost of medications, followed by the cost of provider time to administer treatment (38%). The total annual cost of the risk-based integrated management programme was projected at US$14.4million, entailing US$12.9 per capita or US$40.2 per eligible patient. The estimated annual costs per patient treated with medications for hypertension, diabetes and cholesterol were US$18, US$29 and US$37, respectively. CONCLUSION: Expanding the HEARTS hypertension management and CVD prevention programme to provide services to the entire eligible population in the catchment area may face constraints in physician capacity. A task-sharing model involving shifting of select tasks from doctors to nurses and local community health workers would be essential for the eventual scale-up of primary care services to prevent CVD in Bangladesh.

BACKGROUND: About a fifth of adults in Bangladesh have hypertension; only 13% of Bangladesh adults living with hypertension have their blood pressure controlled (<140/90 mmHg). To address the growing burden of hypertension in low-income and middle-income countries, the WHO recommends implementing the HEARTS technical package. HEARTS outlines a practical approach to cardiovascular disease (CVD) prevention in primary care settings, including risk factor screening, diagnosis, treatment, and patient counseling. The Bangladesh Ministry of Health and Family Welfare and the National Heart Foundation of Bangladesh implemented the HEARTS programme in four district health complexes in Sylhet Division starting in 2019. To inform Bangladesh's health care policies, we translated Bangladesh HEARTS programme effectiveness and cost estimates into projections of national health and budget impact for nationwide programme scale-up. METHODS: We used an interactive, web-based model to project CVD deaths averted based on observed facility-based hypertension control rates and used local costs to obtain budget impact estimates of national HEARTS programme implementation. We also explored three alternative scenarios: reducing medication costs by 50%, increasing team-based care with larger roles for nurses and community health workers, and removing laboratory costs. Relative improvement in hypertension control observed in the HEARTS programme (from 26% to 46% in the four districts over 24 months) was applied to the 13% baseline national control rate resulting in a projected improvement to 33% at national scale. The costs of the hypertension programme were quantified with a standard HEARTS costing tool that was deployed in the four district health complexes. The costing tool recorded and calculated unit costs for hypertension screening, CVD risk assessment, health-care worker time or compensation, and drug prices. FINDINGS: An absolute improvement of 20 percentage points in the national hypertension control rate, from 13% to 33%, would save 9400 lives. Extrapolating local programme costs to the national level resulted in a budget of US$599 million by 2030. Reducing medication costs would lower the budget impact by 42·6%. Increasing team-based care would not substantively affect the cost. Removing laboratory costs would lower the budget by 14%. Combining these innovations would lower the projected cost by 56·9%. INTERPRETATION: Implementing the HEARTS programme in Bangladesh might improve hypertension control and save 9400 lives at a budget impact of $599 million by 2030. Increased task sharing and lower medication prices have potential to reduce costs and make reaching hypertension control goals more affordable and sustainable for Bangladesh. FUNDING: Columbia University Global & Population Health Summer Research Fellowship.

Hyperlipidemia is a risk factor for cardiovascular disease - the leading cause of death globally. Increased understanding of the cost-effectiveness of hyperlipidemia treatment in low- and middle-income countries can guide approaches to hyperlipidemia management in resource-limited environments. We conducted a systematic review of the evidence on the cost-effectiveness of hyperlipidemia medication treatment in low- and middle-income countries using studies published between January 2010 and April 2020. We abstracted study details, including study design, treatment setting, intervention type, health metrics, costs standardized to constant 2019 US dollars, and cost-effectiveness measures including average and incremental cost-effectiveness ratios. Comparisons across studies suggested that treatment via polypill is generally more cost-effective than statin-only therapy, and that primary prevention is more cost-effective than secondary prevention. Treating hyperlipidemia at a threshold of 5.7 mmol/l comes at a higher cost per disability-adjusted life-years averted than at a threshold of 6.2 mmol/l. Most pharmacological treatment strategies for hyperlipidemia were found to be cost-effective in most of the examined low- and middle-income countries.

Heart failure (HF) is a leading global public health problem with >64 million prevalent cases globally. Patients with HF with reduced ejection fraction (HFrEF) from low- and middle-income countries experience a 22% to 58% higher 1-year mortality rate than those in high-income countries.1 Guideline-directed medical therapy (GDMT) consisting of ACE (angiotensin-converting enzyme) inhibitors or ARB (angiotensin receptor blockers) or ARNI (angiotensin receptor-neprilysin inhibitors), -blockers, MRA (mineralocorticoid receptor antagonists), and SGLT2 (sodium-glucose cotransporter 2) inhibitors substantially reduces mortality among patients with HFrEF. These medicines are among the most cost-effective interventions and are thus included as the highest priority health system interventions recommended by the Disease Control Priorities Project.2 Despite this high-quality evidence, GDMT remains widely underutilized in low- and middle-income countries resulting in widespread undertreatment of patients with HFrEF due to health system-, provider-, and patient-level barriers.1 National essential medicines lists (EMLs) promoted by the World Health Organization (WHO) guide countries on which medications to purchase in the setting of limited resources and have resulted in higher procurement and availability of essential medicines in the public sector.3 We provide a cross-sectional analysis of national EMLs in 53 low- and middle-income countries, and availability, price, and affordability of GDMT in select countries to identify potential barriers to access to these essential medicines for patients with HFrEF.

Objectives: Intake of trans fatty acids (TFA) increases the risk of cardiovascular disease. Assessment of TFA exposure in the population is key for determining TFA burden and monitoring change over time. One approach for TFA monitoring is measurement of TFA levels in plasma. Understanding costs associated with this approach can facilitate program planning, implementation and scale-up. This report provides an assessment of costs associated with a pilot program to measure plasma TFA levels in Thailand. Study design: Cost analysis in a laboratory facility in Thailand. Methods: We defined three broad cost modules: laboratory, personnel, and facility costs, which were further classified into sub-components and into fixed and variable categories. Costs were estimated based on the number of processed plasma samples (100–2700 in increments of 50) per year over a certain number of years (1–5), in both USD and Thai Baht. Total cost and average costs per sample were estimated across a range of samples processed. Results: The average cost per sample of analyzing 900 samples annually over 5 years was estimated at USD186. Laboratory, personnel, and facility costs constitute 67%, 23%, and 10% of costs, respectively. The breakdown across fixed costs, such as laboratory instruments and personnel, and variable costs, such as chemical supplies, was 60% and 40%, respectively. Average costs decline as more samples are processed: the cost per sample for analyzing 100, 500, 1500, and 2500 samples per year over 5 years is USD1351, USD301, USD195; and USD177, respectively. Conclusions: Laboratory analysis of plasma TFA levels has high potential for economies of scale, encouraging a long-term approach to TFA monitoring initiatives, particularly in countries that already maintain national biometric repositories. © 2021 The Authors

BACKGROUND: Adolescent childbearing is associated with various health risks to the mother and child, and potentially with adverse socioeconomic outcomes. However, little is known about the role of adolescent childbearing in maternal health outcomes in adulthood. This study investigates the link between childbirth in adolescence and later-life risk of hypertension among women in India. METHODS: We obtained nationally representative data on demographic and health outcomes for 442,845 women aged 25 to 49 from the India National Family Health Survey (NFHS) 2015-16. We assessed the difference in hypertension prevalence between women who gave birth in adolescence (age 10 to 19) and those who did not, for the full sample and various sub-samples, using linear probability models with controls for individual characteristics, hypertension risk factors, and geographic fixed effects. RESULTS: Nearly 40% of the women in the sample gave birth in adolescence. The adjusted probability of being hypertensive in adulthood was 2.3 percentage points higher for this group compared to women who did not give childbirth in adolescence. This added probability was larger for women who gave birth earlier in adolescence (4.8 percentage points) and for women who gave birth more than once in adolescence (3.4 percentage points). CONCLUSIONS: Adolescent childbearing was strongly associated with a higher probability of adult female hypertension in India. This finding illustrates the intertemporal relationship between health risk factors during the life cycle, informing the importance of addressing adverse early life events (e.g. child marriage and adolescent childbirth) for hypertension outcomes among women in India.

Effective control of hypertension at the population level is a global public health challenge. This study shows how improving population coverages at different hypertension care cascade levels could impact population-level hypertension management. We developed an analytical framework and a companion Excel model of multi-level hypertension care cascade entailing awareness, treatment, and control. The model estimates the prevalence of uncontrolled hypertension for different level of population coverages at certain cascade levels. We applied the model to data from Bangladesh and reported prevalence estimates associated with coverage interventions at different cascade levels. The model estimated that if 50% of the unaware hypertensive patients became aware of their hypertensive condition, the prevalence of uncontrolled hypertension would decrease by 1.8 and 1.3 percentage points (8.2% and 5.8% relative reduction), respectively, for constant and variable rates in the status quo setting. When 50% of the aware, but untreated individuals received treatment, the prevalence would decrease by around 0.7 percentage points (3.3% relative reduction). A 50% decrease in the share of treated individuals who did not have hypertension under control, would result in decreasing the prevalence by 2.8 percentage points (12.7% relative reduction). By providing an analytical tool that demonstrates the probable impact of population coverage interventions at certain hypertension care cascade levels, our study endows public health practitioners with vital information to identify gaps and design effective policies for hypertension management.

Antimicrobial stewardship programs (ASPs) have made immense strides in optimizing antibiotic, antifungal, and antiviral use in clinical settings. However, while ASPs are required institutionally by regulatory agencies in the United States and Canada, they are not mandated for transplant centers or programs specifically. Despite the fact that solid-organ transplant recipients in particular are at increased risk of infections from multi-drug resistant organisms, due to host and donor factors and immunosuppressive therapy - there currently are little rigorous data regarding stewardship practices in solid organ transplant populations, and thus no transplant-specific requirements currently exist. Further complicating matters, transplant patients have a wide range of variability regarding their susceptibility to infection, as factors such as surgery of transplant, intensity of immunosuppression, and presence of drains or catheters in-situ, may modify the risk of infection. As such, it is not feasible to have a 'one-size-fits-all' style of stewardship for this patient population. The objective of this whitepaper is to identify opportunities, risk factors and ASP strategies that should be assessed with SOT recipients to optimize antimicrobial use, while producing an overall improvement in patient outcomes. We hope it may serve as a springboard for development of future guidance, and identification of research opportunities.

INTRODUCTION: The 2015 Sustainable Development Goals include the objective of reducing premature mortality from major non-communicable diseases (NCDs) by one-third by 2030. Accomplishing this objective has demographic implications with relevance for countries' health systems and costs. However, evidence on the system-wide implications of NCD targets is limited. METHODS: We developed a cohort-component model to estimate demographic change based on user-defined disease-specific mortality trajectories. The model accounts for ageing over 101 annual age cohorts, disaggregated by sex and projects changes in the size and structure of the population. We applied this model to the context of Bangladesh, using the model to simulate demographic outlooks for Bangladesh for 2015-2030 using three mortality scenarios. The 'status quo' scenario entails that the disease-specific mortality profile observed in 2015 applies throughout 2015-2030. The 'trend' scenario adopts age-specific, sex-specific and disease-specific mortality rate trajectories projected by WHO for the region. The 'target' scenario entails a one-third reduction in the mortality rates of cardiovascular disease, cancer, diabetes and chronic respiratory diseases between age 30 and 70 by 2030. RESULTS: The status quo, trend and target scenarios projected 178.9, 179.7 and 180.2 million population in 2030, respectively. The cumulative number of deaths during 2015-2030 was estimated at 17.4, 16.2 and 15.6 million for each scenario, respectively. During 2015-2030, the target scenario would avert a cumulative 1.73 million and 584 000 all-cause deaths compared with the status quo and trend scenarios, respectively. Male life expectancy was estimated to increase from 71.10 to 73.47 years in the trend scenario and to 74.38 years in the target scenario; female life expectancy was estimated to increase from 73.68 to 75.34 years and 76.39 years in the trend and target scenarios, respectively. CONCLUSION: The model describes the demographic implications of NCD prevention and control targets, estimating the potential increase in life expectancy associated with achieving key NCD reduction targets. The results can be used to inform future health system needs and to support planning for increased healthcare coverage in countries.

BACKGROUND: Uncontrolled hypertension and tobacco use are two major public health issues that have implications for reproductive outcomes. This paper examines the association between tobacco-use status and uncontrolled hypertension among prime childbearing age (20-35) women in India. METHODS: We used the India National Family Health Survey (NFHS-4) 2015-2016 to obtain data on hypertension status and tobacco use for 356,853 women aged 20-35. We estimated multivariate logistic regressions to obtain the adjusted odds ratio for tobacco users in favor of having uncontrolled hypertension. We examined the adjusted odds at different wealth index quintiles, at different educational attainment, and at different level of nutritional status measured by body mass index. RESULTS: We found that the odds of having uncontrolled hypertension for the tobacco user women in India was 1.1 (95% CI: 1.01-1.19) times that of tobacco non-users at prime childbearing age. The odds were higher for tobacco-users at the poorest quintile (1.27, 95% CI: 1.14-1.42) and with no education (1.22, 95% CI: 1.10-1.34). The odds were also higher for tobacco-users who were overweight (1.88, 95% CI: 1.57-2.29) or obese (2.82, 95% CI: 1.88-4.24). CONCLUSIONS: Our findings highlight the disproportionate dual risk of uncontrolled hypertension and tobacco use among lower-income women of prime childbearing age, identifying an opportunity for coordinated tobacco control and hypertension prevention initiatives to ensure better health of reproductive-age women in India.

INTRODUCTION: The Eastern Mediterranean Region (EMR) has experienced several protracted humanitarian crises. The affected population are served by eight EWARN systems for outbreak detection and response. Our aim was to compare structure, function, and performance of the systems, adherence to current guidance, and note emerging lessons. METHODS: This study included a review of published and unpublished literature, a structured survey, and interviews. RESULTS: Findings showed all systems adhered to basic EWARN structure. Four of eight systems had electronic platforms while one was implementing. Regarding key EWARN function of outbreak detection, out of the 35 health conditions, 26 were communicable diseases and nine were non-communicable; only two systems focused on epidemic-prone diseases. Half the systems achieved ≥60% population coverage, five achieved ≥80% reporting timeliness, six achieved ≥80% reporting completeness, and seven achieved verification of ≥80% of alerts of suspected outbreaks. CONCLUSION: Findings showed that the systems followed EWARN structure while increasing adoption of electronic platforms. Performance, including timeliness and completeness of reporting, and timely verification of alerts, were optimal for most of the systems. However, population coverage was low for most of the systems, and EWARN's primary focus of outbreak detection was being undermined by increasing number of non-epidemic diseases.

Hypertension in low-income and middle-income countries (LMICs) is largely undiagnosed and uncontrolled, representing an untapped opportunity for public health improvement. Implementation of hypertension control strategies in low-resource settings depends in large part on cost considerations. However, evidence on the cost-effectiveness of hypertension interventions in LMICs is varied across geographical, clinical and evaluation contexts. We conducted a comprehensive search for published economic evaluations of hypertension treatment programmes in LMICs. The search identified 71 articles assessing a wide range of hypertension intervention designs and cost components, of which 42 studies across 15 countries reported estimates of cost-effectiveness. Although comparability of results was limited due to heterogeneity in the interventions assessed, populations studied, costs and study quality score, most interventions that reported cost per averted disability-adjusted life-year (DALY) were cost-effective, with costs per averted DALY not exceeding national income thresholds. Programme elements that may reduce cost-effectiveness included screening for hypertension at younger ages, addressing prehypertension, or treating patients at lower cardiovascular disease risk. Cost-effectiveness analysis could provide the evidence base to guide the initiation and development of hypertension programmes.

BACKGROUND: We revisited the association between progress in MPOWER implementation from 2008 to 2016 and smoking prevalence from 2009 to 2017 and offered an in-depth understanding of differential outcomes for various country groups. METHODS: We used data from six rounds of the WHO Reports on the Global Tobacco Epidemic and calculated a composite MPOWER Score for each country in each period. We categorised the countries in four initial conditions based on their tobacco control preparedness measured by MPOWER score in 2008 and smoking burden measured by age-adjusted adult daily smoking prevalence in 2006: (1) High MPOWER - high prevalence (HM-HP). (2) High MPOWER - low prevalence (HM-LP). (3) Low MPOWER - high prevalence (LM-HP). (4) Low MPOWER - low prevalence (LM-LP). We estimated the association of age-adjusted adult daily smoking prevalence with MPOWER Score and cigarette tax rates using two-way fixed-effects panel regression models including both year and country fixed effects. RESULTS: A unit increase of the MPOWER Score was associated with 0.39 and 0.50 percentage points decrease in adult daily smoking prevalence for HM-HP and HM-LP countries, respectively. When tax rate was controlled for separately from MPOWE, an increase in tax rate showed a negative association with daily smoking prevalence for HM-HP and LM-LP countries, while the MPOWE Score showed a negative association for all initial condition country groups except for LM-LP countries. CONCLUSION: A decade after the introduction of the WHO MPOWER package, we observed that the countries with higher initial tobacco control preparedness and higher smoking burden were able to reduce the adult daily smoking prevalence significantly.

OBJECTIVE: Psychosocial factors, such as environmental stressors, can increase the risk of hypertension. This study examines the role of the household environment in hypertension outcomes by assessing the link between female hypertension status and spousal alcohol consumption in Nepal. STUDY DESIGN: This is a cross-sectional study. METHODS: We used the 2016 Nepal Demographic and Health Survey to assess differences in hypertension outcomes in women aged 15 to 49 years whose husbands drink alcohol and in those whose husbands do not. We estimated a multinomial logistic model to obtain adjusted differences in the likelihood of being hypertensive between the two groups. We also examined several socio-economic conditions across the two groups to discuss various aspects of the association. RESULTS: After controlling for anthropometric and various sociodemographic attributes, we find that women whose husbands drink alcohol were 2.5 percentage points (95% confidence interval [CI]: -0.31, 5.31) more likely to be hypertensive than women whose husbands do not. They were also more likely to experience food insecurity, to experience spousal violence, and to consume tobacco products. Among women whose husbands became intoxicated ('got drunk') very often, the likelihood of being hypertensive was 4.0 percentage points (95% CI: -0.26, 7.67) higher than among women whose husbands do not drink alcohol. CONCLUSION: Women whose husbands consume alcohol have an elevated risk of being hypertensive, illustrating the association between hypertension and the household environment. The findings document the added hypertension burden in socially vulnerable population groups and can inform initiatives to reduce alcohol consumption in Nepal.

Since the ratification of the World Health Organization Framework Convention on Tobacco Control in 2004, Pakistan has made modest but continued progress in implementing various tobacco control measures. By 2014, substantial progress was achieved in areas of monitoring, mass media antitobacco campaigns, and advertising bans. However, the findings from the 2014 Global Adult Tobacco Survey of Pakistan show significant differences in antitobacco campaign exposure among individuals of different educational attainment. Given this large variation in noticing antitobacco information, this paper analyzes how heterogeneity in treatment exposure may differentially impact tobacco-use prevalence across household groups. Household-level tobacco-use prevalence in 2014 was, respectively, 56% and 48% for the low- and high-education households. The gap in tobacco-use prevalence between the two educational groups further widens post 2014. We find that, on average, individuals with higher than primary education are 14 percentage points and 6 percentage points more likely to notice anticigarette and antismokeless tobacco information in 2014, respectively. Subsequently, in 2016, high-education households experienced a 3.6 percentage point higher reduction in tobacco-use prevalence compared to the low-education households. These findings motivate policies to enhance the outreach of tobacco control measures across different educational groups.

Background Access to medicines is important for long-term care of cardiovascular diseases and hypertension. This study provides a cross-country assessment of availability, prices, and affordability of cardiovascular disease and hypertension medicines to identify areas for improvement in access to medication treatment. Methods and Results We used the World Health Organization online repository of national essential medicines lists (EMLs) for 53 countries to transcribe the information on the inclusion of 12 cardiovascular disease/hypertension medications within each country's essential medicines list. Data on availability, price, and affordability were obtained from 84 surveys in 59 countries that used the World Health Organization's Health Action International survey methodology. We summarized and compared the indicators across lowest-price generic and originator brand medicines in the public and private sectors and by country income groups. The average availability of the select medications was 54% in low- and lower-middle-income countries and 60% in high- and upper-middle-income countries, and was higher for generic (61%) than brand medicines (41%). The average patient median price ratio was 80.3 for brand and 16.7 for generic medicines and was higher for patients in low- and lower-middle-income countries compared with high- and upper-middle-income countries across all medicine categories. The costs of 1 month's antihypertensive medications were, on average, 6.0 days' wage for brand medicine and 1.8 days' wage for generics. Affordability was lower in low- and lower-middle-income countries than high- and upper-middle-income countries for both brand and generic medications. Conclusions The availability and accessibility of pharmaceuticals is an ongoing challenge for health systems. Low availability and high costs are major barriers to the use of and adherence to essential cardiovascular disease and antihypertensive medications worldwide, particularly in low- and lower-middle-income countries.

BACKGROUND: There is limited research on noncommunicable diseases (NCDs) in humanitarian settings despite the overall global burden and disproportionate growth in many conflicts and disaster-prone settings. This study aimed to determine the prevalence of NCDs and assess the perceived effect of conflict on NCD severity and access to treatment among conflict-affected adults (>/= 30 years) in Ukraine. METHODS AND FINDINGS: We conducted two population-representative, stratified, cross-sectional household surveys: one among adult internally displaced people (IDPs) throughout Ukraine and one among adults living in Donbas in eastern Ukraine. One randomly selected adult per household answered questions about their demographics, height and weight, diagnosed NCDs, access to medications and healthcare since the conflict began, as well as questions assessing psychological distress, trauma exposure, and posttraumatic stress disorder. More than half of participants reported having at least one NCD (55.7% Donbas; 59.8% IDPs) A higher proportion of IDPs compared to adults in Donbas experienced serious psychological distress (29.9% vs. 18.7%), interruptions in care (9.7-14.3% vs. 23.1-51.3%), and interruptions in medication than adults in Donbas (14.9-45.6% vs. 30.2-77.5%). Factors associated with perceived worsening of disease included psychological distress (p: 0.002-0.043), displacement status (IDP vs. Donbas) (p: <0.001-0.011), interruptions in medication (p: 0.002-0.004), and inability to see a doctor at some point since the start of the conflict (p: <0.001-0.008). CONCLUSIONS: Our study found a high burden of NCDs among two conflict-affected populations in Ukraine and identified obstacles to accessing care and medication. Psychological distress, interruptions to care, and interruptions in medication were all reported by a higher proportion of IDPs than adults in Donbas. There is a need for targeted policies and programs to support the unique needs of displaced conflict-affected individuals in Ukraine that address the economic and perceived barriers to NCD treatment and care.

OBJECTIVE: Carbonated beverage consumption is associated with various adverse health conditions such as obesity, type 2 diabetes and CVD. Pakistan has a high burden of these health conditions. At the same time, the carbonated beverage industry is rapidly growing in Pakistan. In this context, we analyse the trends and socioeconomic factors associated with carbonated beverage consumption in Pakistan. DESIGN: We use six waves of the cross-sectional household surveys from 2005-2006 to 2015-2016 to analyse carbonated beverage consumption. We examine the trends in carbonated beverage consumption-prevalence for different economic groups categorised by per capita household consumption quintiles. We estimate the expenditure elasticity of carbonated beverages for these groups using a two-stage budgeting system framework. We also construct concentration curves of carbonated beverage expenditure share to analyse the burden of expenditure across households of different economic status. SETTING: Pakistan. PARTICIPANTS: Nationally representative sample of households in respective survey waves. RESULTS: We find that the wealthier the household, the higher is the prevalence of carbonated beverage consumption, and the prevalence has increased for all household groups over time. From the expenditure elasticity analysis, we observe that carbonated beverages are becoming an essential part of food consumption particularly for wealthier households. And, lastly, poorer households are bearing a larger share of carbonated beverage expenditure in 2014-2016 than that in 2006-2008. CONCLUSION: Carbonated beverages are becoming an increasingly essential part of household food consumption in Pakistan. Concerns about added sugar intake can prompt consideration of public health approaches to reduce dietary causes of the disease burden in Pakistan.

Noncommunicable diseases (NCDs), such as heart disease, cancer, diabetes, and chronic respiratory disease, are responsible for seven out of every 10 deaths worldwide. While NCDs are associated with aging in high-income countries, this representation is often misleading. Over one-third of the 41 million annual deaths from NCDs occur prematurely, defined as under 70 years of age. Most of those deaths occur in low- and middle-income countries (LMICs) where surveillance, treatment, and care of NCDs are often inadequate. In addition to high health and social costs, the economic costs imposed by such high numbers of excess early deaths impede economic development and contribute to global and national inequity. In higher-income countries, NCDs and their risks continue to push health care costs higher. The burden of NCDs is strongly intertwined with economic conditions for good and for harm. Understanding the multiple ways they are connected-through risk factor exposures, access to quality health care, and financial protection among others-will determine which countries are able to improve the healthy longevity of their populations and slow growth in health expenditure particularly in the face of aging populations. The aim of this Special Collection is to provide new evidence to spur those actions.