Cigarette smoking and homelessness are interconnected public health problems that contribute to health disparities. Smoking is common among persons with disabilities, mental health, and/or substance use disorders, as well as those living below the federal poverty level. These are the same populations living in permanent supportive housing, which is subsidized housing with closely linked or on-site voluntary social and/or medical services for formerly homeless adults. Among persons residing in permanent supportive housing, cigarette smoking not only presents an opportunity cost (ie, something that detracts from an essential need), threatening housing stability, but also leads to adverse health outcomes. Smoking cessation could improve health outcomes and free up funds to enhance housing stability. Smoke-free policies and cessation services, 2 evidence-based approaches, could provide the support needed for permanent supportive housing residents to quit smoking. However, such policies are uncommon in permanent supportive housing, in part because of concerns that they may increase evictions. We describe barriers to and opportunities for increasing access to comprehensive smoke-free policies and smoking cessation services in permanent supportive housing. By facilitating the implementation of such policies, permanent supportive housing could empower residents to engage in smoking cessation while avoiding unintended consequences.

BACKGROUND: Despite vaccination efforts and documentation of elimination of indigenous measles in 2000, the United States (US) experienced a marked increase in imported cases and outbreaks of measles in 2011. Due to the high infectiousness and potential severity of measles, these outbreaks require a vigorous response from public health institutions. The effort and resources required to respond to these outbreaks are likely to impose a significant economic burden on these institutions. OBJECTIVE: To estimate the economic burden of measles outbreaks (defined as ≥3 epidemiologically linked cases) on the local and state public health institutions in the US in 2011. METHODS: From the perspective of local and state public health institutions, we estimated personnel time and resources allocated to measles outbreak response in local and state public health departments, and estimated the corresponding costs associated with these outbreaks in the US in 2011. We used cost and resource utilization data from previous studies on measles outbreaks in the US and, relying on outbreak size classification based on a case-day index, we estimated costs incurred by local and state public health institutions. RESULTS: In 2011, the US experienced 16 outbreaks with 107 confirmed cases. The average duration of an outbreak was 22 days (range: 5-68). The total estimated number of identified contacts to measles cases ranged from 8936 to 17,450, requiring from 42,635 to 83,133 personnel hours. Overall, the total economic burden on local and state public health institutions that dealt with measles outbreaks during 2011 ranged from an estimated $2.7 million to $5.3 million US dollars. CONCLUSION: Investigating and responding to measles outbreaks imposes a significant economic burden on local and state health institutions. Such impact is compounded by the duration of the outbreak and the number of potentially susceptible contacts.

INTRODUCTION: Following World Health Organization recommendations set forth in the Global Framework for Immunization Monitoring and Surveillance, Costa Rica in 2009 became the first country to implement integrated vaccine-preventable disease (iVPD) surveillance, with support from the U.S. Centers for Disease Control and Prevention (CDC) and the Pan American Health Organization (PAHO). As surveillance for diseases prevented by new vaccines is integrated into existing surveillance systems, these systems could cost more than routine surveillance for VPDs targeted by the Expanded Program on Immunization. OBJECTIVES: We estimate the costs associated with establishing and subsequently operating the iVPD surveillance system at a pilot site in Costa Rica. METHODS: We retrospectively collected data on costs incurred by the institutions supporting iVPD surveillance during the preparatory (January 2007 through August 2009) and implementation (September 2009 through August 2010) phases of the iVPD surveillance project in Costa Rica. These data were used to estimate costs for personnel, meetings, infrastructure, office equipment and supplies, transportation, and laboratory facilities. Costs incurred by each of the collaborating institutions were also estimated. RESULTS: During the preparatory phase, the estimated total cost was 128,000 U.S. dollars (US$), including 64% for personnel costs. The preparatory phase was supported by CDC and PAHO. The estimated cost for 1 year of implementation was US$ 420,000, including 58% for personnel costs, 28% for laboratory costs, and 14% for meeting, infrastructure, office, and transportation costs combined. The national reference laboratory and the PAHO Costa Rica office incurred 64% of total costs, and other local institutions supporting iVPD surveillance incurred the remaining 36%. CONCLUSIONS: Countries planning to implement iVPD surveillance will require adequate investments in human resources, laboratories, data management, reporting, and investigation. Our findings will be valuable for decision makers and donors planning and implementing similar strategies in other countries.

In 2010, an expert advisory panel convened by the World Health Organization to assess the feasibility of measles eradication concluded that (1) measles can and should be eradicated, (2) eradication by 2020 is feasible if measurable progress is made toward existing 2015 measles mortality reduction targets, (3) measles eradication activities should occur in the context of strengthening routine immunization services, and (4) measles eradication activities should be used to accelerate control and elimination of rubella and congenital rubella syndrome (CRS). The expert advisory panel also emphasized the critical role of research and innovation in any disease control or eradication program. In May 2011, a meeting was held to identify and prioritize research priorities to support measles and rubella/CRS control and potential eradication activities. This summary presents the questions identified by the meeting participants and their relative priority within the following categories: (1) measles epidemiology, (2) vaccine development and alternative vaccine delivery, (3) surveillance and laboratory methods, (4) immunization strategies, (5) mathematical modeling and economic analyses, and (6) rubella/CRS control and elimination.

INTRODUCTION: Child Health Days (CHDs) are increasingly used by countries to periodically deliver multiple maternal and child health interventions as time-limited events, particularly to populations not reached by routine health services. In countries with a weak health infrastructure, this strategy could be used to reach many underserved populations with an integrated package of services. In this study, we estimate the incremental costs, impact, cost-effectiveness, and return on investment of 2 rounds of CHDs that were conducted in Somalia in 2009 and 2010. METHODS: We use program costs and population estimates reported by the World Health Organization and United Nations Children's Fund to estimate the average cost per beneficiary for each of 9 interventions delivered during 2 rounds of CHDs implemented during the periods of December 2008 to May 2009 and August 2009 to April 2010. Because unstable areas were unreachable, we calculated costs for targeted and accessible beneficiaries. We model the impact of the CHDs on child mortality using the Lives Saved Tool, convert these estimates of mortality reduction to life years saved, and derive the cost-effectiveness ratio and the return on investment. RESULTS: The estimated average incremental cost per intervention for each targeted beneficiary was $0.63, with the cost increasing to $0.77 per accessible beneficiary. The CHDs were estimated to save the lives of at least 10,000 or 500,000 life years for both rounds combined. The CHDs were cost-effective at $34.00/life year saved. For every $1 million invested in the strategy, an estimated 615 children's lives, or 29,500 life years, were saved. If the pentavalent vaccine had been delivered during the CHDs instead of diphtheria-pertussis-tetanus vaccine, an additional 5000 children's lives could have been saved. CONCLUSIONS: Despite high operational costs, CHDs are a very cost-effective service delivery strategy for addressing the leading causes of child mortality in a conflict setting like Somalia and compare favorably with other interventions rated as health sector "best buys" in sub-Saharan Africa.

Elinor Ostrom is the co-recipient of the 2009 Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel “for her analysis of economic governance, especially the commons” [1], making this an opportune time to propose a strategy to improve immunization coverage based on the concept of “commons”, which refers to collectively owned resources. | In September 2000, building upon a decade of major United Nations conferences and summits, world leaders adopted the United Nations Millennium Declaration, committing their nations to a new global partnership to reduce extreme poverty and setting out a series of time-bound targets with a deadline of 2015, that have become known as the Millennium Development Goals (MDGs) [2]. The fourth goal (MDG 4) aims to reduce mortality among children less than 5 years of age by two-thirds, between 1990 and 2015. Although deaths among children under 5 years of age declined by 28% between 1990 and 2008, an estimated 8.8 million children under the age of five died in 2008, of which nearly a quarter were attributable to diseases preventable by vaccines [3], [4]. To set priorities based on costs and benefits of solutions to confront ten great global challenges, for the Copenhagen Consensus 2008, a panel of economic experts comprising eight of the world's most distinguished economists ranked expanded immunization coverage for children as one of the most cost-effective solutions to confront diseases at the global level [5].