Two linked cases of legionella with an unusual industrial Two linked cases of legionellosis with an unusual industrial source Noelene S O'Keefe,* Kristina A Heinrich- Morrison,† Bruce McLaren‡ * Project Officer, Legionella Program, Environmental Health, † Public Health Nurse, ‡ Medical Officer, Communicable Diseases Section, Department of Human Services, 17/120
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Advancement of global health: key messages from the
Disease Control Priorities Project
Ramanan Laxminarayan, Anne J Mills, Joel G Breman, Anthony R Measham, George Alleyne, Mariam Claeson, Prabhat Jha, Philip Musgrove, Jeﬀ rey Chow, Sonbol Shahid-Salles, Dean T Jamison The Disease Control Priorities Project (DCPP), a joint project of the Fogarty International Center of the US National Lancet 2006; 367: 1193–208
Institutes of Health, the WHO, and The World Bank, was launched in 2001 to identify policy changes and intervention Published Online
strategies for the health problems of low-income and middle-income countries. Nearly 500 experts worldwide
compiled and reviewed the scientiﬁ c research on a broad range of diseases and conditions, the results of which are 6736(06)68440-7
published this week. A major product of DCPP, Disease Control Priorities in Developing Countries, 2nd edition (DCP2), Resources for the Future,
focuses on the assessment of the cost-eﬀ ectiveness of health-improving strategies (or interventions) for the conditions 1616 P Street NW Suite 600,
responsible for the greatest burden of disease. DCP2 also examines crosscutting issues crucial to the delivery of Washington, DC 20036, USA
quality health services, including the organisation, ﬁ nancial support, and capacity of health systems. Here, we
J Chow MEM); London School of
summarise the key messages of the project.
Hygiene and Tropical Medicine,
London, UK (Prof A J Mills PhD);
Rapid declines in mortality rates and overall improvement Gates Foundation), was launched in 2001 to identify policy Fogarty International Center,
in health are among the least recognised advances of the changes and intervention strategies for the health problems National Institutes of Health,
second half of the 20th century. Life expectancy increased of countries in need.6–8 The project follows on from the Bethesda, MD, USA
by an average of 6·3 years per decade worldwide between ﬁ rst edition of the Disease Control Priorities in Developing A R Measham MD, 1960 and 1990, albeit more slowly since then. Furthermore, Countries9 and the World Bank’s 1993 Development P Musgrove PhD, cross-country diﬀ erences in life expectancy have fallen Report,10 which attempted to make global comparisons of S Shahid-Salles MPH, greatly since 1950, although income inequality between interventions to improve health in developing countries. Prof D T Jamison PhD); Pan
American Health Organization,
and within countries has risen. Overall, if one properly The aim of DCPP was to generate knowledge to assist Washington, DC, USA
accounts for convergence across countries in health decision makers in developing countries—especially those (Sir G Alleyne MD); World Bank,
conditions, global inequalities are falling.1,2 in the public sector—to realise the potential of aﬀ ordable, Washington, DC, USA
Despite huge overall global improvements in health, eﬀ ective interventions to rapidly improve the health and (M Claeson MD); Public Health
Sciences, University of Toronto,
many low-income and middle-income countries have not welfare of their populations. The main product of DCPP is and Centre for Global Health
shared in the gains or have fallen further behind high- a second, much expanded and updated revision of Disease Research, St Michael’s Hospital,
income countries. As well as aﬀ ecting wellbeing, Control Priorities in Developing Countries. The Disease McLaughlin Centre for
poor health impedes economic growth and poverty reduc- Control Priorities in Developing Countries, 2nd edition Molecular Medicine, Toronto,
Ontario, Canada (P Jha MD);
tion. From 1990 to 2001 the mortality rate of those aged (DCP2), has 73 wide-ranging chapters, compiled by almost Global Health, Health Aﬀ airs,
5 years or younger increased or remained constant in 500 experts, covering disease conditions, their burdens Bethesda, MD, USA
23 countries. In another 53 countries (including China), and risk factors, intervention eﬀ ectiveness and cost- (P Musgrove PhD); and
the fall in mortality in this age group was less than half the eﬀ ectiveness, health systems, and ﬁ nancing. Table 1 Population Reference Bureau,
Washington, DC, USA
4·3% per year required to reach the fourth Millennium provides comparative disease burdens in low-income, (S Shahid-Salles MPH) Development Goal of reducing mortality in those younger middle-income, and high-income countries, and worldwide Correspondence to: of major diseases. Here, we summarise the key messages Dr Ramanan Laxminarayan Income inequality is only one reason for health inequality. about intervention priorities (table 2) and, to a lesser extent, ramanan@rﬀ .org
The experiences of European countries in the late 19th and those about health systems (panel 1), development early 20th centuries3 and, more recently, of Bangladesh, assistance for health (panel 2), and research and product China, Costa Rica, Cuba, Sri Lanka, and the Kerala state of India, among many others, indicate that improvements in Additionally, DCPP has resulted in an updated health can arise without high or rapidly growing incomes assessment of the global burden of disease and risk factors,7 and that the correct policies can greatly reduce mortality. a review of documented successes at improving population Globalisation has helped to diﬀ use knowledge about the health,11 and many other publications12,13 and working best interventions and methods for their delivery. Both papers, including a major review of malaria’s experience and the results of analytical work suggest that the pace of such dissemination into a country, and the willingness and ability of those who live there to act on the Intervention priorities
information, governs the pace of health improvement DCP2 identiﬁ es highly cost-eﬀ ective opportunities to improve health that policymakers are ignoring or The Disease Control Priorities Project (DCPP), a joint underfunding and details prevalent investments that are eﬀ ort of the Fogarty International Center of the US not cost eﬀ ective. The perspective taken is that of National Institutes of Health (NIH), WHO, and The World allocation of public ﬁ nances to meet social goals of Bank (and with substantial funding from the Bill & Melinda improving population health and reducing ﬁ nancial risks www.thelancet.com Vol 367 April 8, 2006
Low-income and middle-income countries
DALY* (n=1 387 426)DALY † (n=1 260 643)DALY* (n=149 161) DALY † (n=148 316)DALY* (n=1 536 587) Communicable diseases, pregnancy outcomes, and nutritional deﬁ ciencies
Sexually transmitted infections (not HIV)0·7 Non-communicable conditions
Data are %. *DALY calculated at 3% per year discount rate with no age-weights. †DALY analagous to DALY except that it includes stillbirths in estimates of burden and assumes a gradual acquisition of life potential that allows burden associated with a death near the time of birth to grow gradually with age rather than instantaneously increasing from 0 to a high value at birth or some earlier time.
Table 1: Burden of disease in low-income and middle-income countries, high-income countries, and worldwide, 20017
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Cost per DALY
Thousands of DALYs
Burden of target
averted*† per 20%
increase in coverage
Neglected low-cost opportunities in south Asia
Increased coverage of traditional EPI programme Peer-based programmes for at-risk groups (eg, commercial sex workers) to disseminate information, services (clean needles and condoms), and teach speciﬁ c skills School-based interventions to disseminate information Prevention of mother-to-child transmission with antiretroviral therapy Surgical ward in district hospital, primarily for obstetrics, trauma, and injury Training of lay ﬁ rst-responders and volunteer paramedics Childhood vaccination against endemic disease Directly observed short-course chemotherapy Lower acute respiratory illnesses of children younger than age 5 years Community-based or facility-based case management of non-severe cases Case management package, including community-based and facility-based care for non-severe cases and hospital-based care for severe cases Management of acute myocardial infarction with aspirin and β blocker Primary prevention of coronary artery disease with legislation, substituting 2% of trans fat with polyunsaturated fat, at $0·50 per adult Secondary prevention of congestive heart failure with ACE inhibitors and β blockers incremental to diuretics Secondary prevention of myocardial infarction and stroke with polypill, containing aspirin, β blocker, thiazide diuretic, ACE inhibitor, and statin Tax policy to increase price of cigarettes by 33% Advertising bans, health information dissemination, tobacco supply reductions, and smoking restrictions Improved quality of comprehensive emergency obstetric care Improved overall quality and coverage of care Neonatal packages targeted at families, communities, and clinics Neglected low-cost opportunities in sub-Saharan Africa
Second opportunity measles vaccination‡ Increased coverage of traditional EPI programme Increased speeding penalties, and media and law enforcement Intermittent preventive treatment during pregnancy‡ Surgical ward in a district hospital, primarily for obstetrics, trauma, and injury Training of lay ﬁ rst-responders and volunteer paramedics www.thelancet.com Vol 367 April 8, 2006
Integrated management of childhood illnesses‡ Case management of non-severe lower acute respiratory illnesses at community or facility level Case management package, including community-based or facility-based care for non-severe cases and hospital-based care for severe lower acute respiratory illnesses Management of acute myocardial infarction with aspirin and β blocker Primary prevention of coronary artery disease with legislation, substituting 2% of trans fat with polyunsaturated fat, at $0·50 per adult Secondary prevention of congestive heart failure with ACE inhibitors and β blockers incremental to diuretics Secondary prevention of myocardial infarction and stroke with polypill, containing aspirin, β blocker, thiazide diuretic, ACE inhibitor, and statin Peer-based programmes for at-risk groups (eg, commercial sex workers) to disseminate information and teach speciﬁ c skills Diagnosis and treatment of sexually-transmitted diseases‡ Prevention and treatment of coinfection with Mycobacterium tuberculosis‡ Prevention of mother-to-child transmission with antiretroviral therapy Improved quality of comprehensive emergency obstetric care Improved overall quality and coverage of care Neonatal packages targeted at families, communities, and clinics High-cost interventions in south Asia
Episodic treatment with new antidepressant drug (SSRI)1003–1449 Episodic or maintenance psychosocial treatment plus treatment with new antidepressant drug (SSRI) Primary prevention of stroke and ischaemic and hypertensive heart disease with aspirin, β blocker, and statin, incremental to policy-induced behaviour change, at 15% risk of cardiovascular disease event over 10 years Primary prevention of stroke and ischaemic and hypertensive heart disease with a polypill, containing aspirin, β blocker, thiazide diuretic, ACE inhibitor, and statin, at 15% risk of cardiovascular disease event over 10 years Primary prevention of diabetes, ischaemic heart disease, and stroke through policy that replaces saturated fat with monounsaturated fat in manufactured foods, accompanied by a public education campaign Primary prevention of diabetes, ischaemic heart disease, and stroke through legislation that reduces salt content plus public education Acute management with recombinant tissue plasminogen activator within 48 h of onset Acute management with heparin within 48 h of onset Secondary prevention with carotid endarterectomy Oral rehydration therapy if package cost is >$2·30 per child per episode Isoniazid treatment for latent endemic disease in patients uninfected with HIV Antipsychotic medication and psychosocial treatment for schizophrenia Valproate and psychosocial treatment for bipolar disorder Management of acute myocardial infarction with streptokinase or tissue plasminogen activator, incremental to aspirin and Secondary prevention of ischaemic heart disease with statin, incremental to aspirin, β blocker, and ACE inhibitor Secondary prevention of ischaemic heart disease with coronary artery bypass graft www.thelancet.com Vol 367 April 8, 2006
High-cost interventions in sub-Saharan Africa
Oral rehydration therapy if cost per episode is >$2·80 per child Antiretroviral therapy in populations with low adherence‡ Primary prevention of stroke and ischaemic and hypertensive heart disease with aspirin, β blocker, and statin, incremental to policy-induced behaviour change, at 15% risk of cardiovascular disease event over 10 years Primary prevention of diabetes, ischaemic heart disease, and stroke through policy that replaces saturated fat with monounsaturated fat in manufactured foods, accompanied by a public education campaign Primary prevention of diabetes, ischaemic heart disease, and stroke through legislation that reduces salt content plus public education Acute management with recombinant tissue plasminogen activator within 48 h of onset Acute management with heparin within 48 h of onset Secondary prevention with carotid endarterectomy Isoniazid treatment for latent endemic disease in patients uninfected with HIV Management of acute myocardial infarction with streptokinase or tissue plasminogen activator, incremental to aspirin and Secondary prevention of ischaemic heart disease with statin, incremental to aspirin, β blocker, and ACE inhibitor Secondary prevention of ischaemic heart disease with coronary artery bypass graft *Ranges represent variation in point estimates of cost-eﬀ ectiveness, DALYs averted, or burden of disease for diﬀ erent interventions. Point estimates of cost-eﬀ ectiveness and DALYs averted obtained from DCP2 6 or calculated as midpoint of range estimates reported. Burden of disease estimates obtain ed from reference 7. †Avertable DALYs per 20% increase in treatment coverage in a hypothetical sample population of 1 million people· ‡Only assessed for sub-Saharan Africa.
Table 2: Neglected low-cost opportunities and high-cost interventions in south Asia and sub-Saharan Africa
of ill-health. Careful selection of priorities makes limited should, all else being equal, be used less, whereas those resources go further and encourages aid agencies and with a low price should be used to a greater extent. development partners to invest in the expansion of health The cost-eﬀ ectiveness-related ﬁ ndings in DCP2 are subject to several caveats, and we encourage readers to importance of increasing resources for the implementation note the order of magnitude o f each estimate rather than of these interventions and meeting of broader objectives, the speciﬁ c number. Final estimates were calculated such as the Millennium Development Goals. These either with cost-eﬀ ectiveness numbers drawn from published work or with standardised resource costs Cost-eﬀ ectiveness is presented as US$ per disability- adapted from WHO’s CHOICE project.15 Also, the cost- adjusted life year (DALY) averted. DALYs combine years eﬀ ectiveness estimates are not varied with the scale of the lived with disability and years lost to premature death in a intervention, and apply to countries in which institutional single metric. Cost-eﬀ ectiveness is only one consideration and technical capacity in relation to health is close to the in allocating resources to speciﬁ c diseases and average for their World Bank region. The estimates are interventions; epidemiological, medical, political, ethical, based on the best available data, which are often weak. cultural, and budgetary factors also aﬀ ect such decisions. Pharmacological and other interventions within health- Interpretation of the cost-eﬀ ectiveness ratio as the price of care services are over-represented in our assessment— equivalent units of health, using diﬀ erent interventions, is environmental, agricultural, legal, and health promoting a useful approach to deploy cost-eﬀ ectiveness information interventions have received less attention, primarily alongside these other considerations in setting priorities. because of the complexity of evaluating them.
Cost-eﬀ ectiveness information makes policymakers aware Figure 1 and ﬁ gure 2 show cost-eﬀ ectiveness estimates of diﬀ erences in the price of improving health with diﬀ erent interventions. Interventions with a high price 218 interventions). Cost-eﬀ ectiveness ranges should not www.thelancet.com Vol 367 April 8, 2006
Panel 1: Strengthening of health systems
Strengthening health system performance is a wide-ranging subject, likely to require action on many fronts and management levels. It requires attention to the various functions of the health system, especially the various dimensions of management, as well as to associations between the system, its clients (patients), and their communities. Evidence for which approaches work best is limited ● Strengthen accountability of health systems to communities and ensure users have a voice and can inﬂ uence priorities—in Burkina Faso, participation by communities in public primary health-care clinics increased immunisation coverage, essential drug availability, and proportion of women with two or more prenatal visits ● Revise regulations that govern private providers—regulations are often outdated and poorly enforced; revision of regulations to permit drug shops to stock a small set of oral antibiotics, for example, would allow more constructive engagement between sales staﬀ and inspectors as well as increase drug availability ● Distinguish more clearly the roles of purchaser and provider within public services—though there are few successful examples and major reforms have encountered severe implementation diﬃ ● Achieve the appropriate balance of vertical and horizontal modes of organisation and management of service provision—the pendulum swings between focused, disease-speciﬁ c support and broader health-service or health-system support. Disease-focused eﬀ orts make most sense in situations of weak ins titutional capacity, poor controls on use of public money, and highly constrained resource availability. But such eﬀ orts should be designed and implemented in ways that support longer-term system strengthening ● Use contracts with non-governmental organisations to deliver services where government capacity is weak—eg, in remote areas—or public provision less eﬀ ective—eg, some HIV prevention interventions. In Cambodia, results of a comparison of government provision with two forms of contracting to non-governmental organisations showed that increases in coverage of key interventions were higher in the contracted districts, and that the poor especially beneﬁ ted ● Reduce migration of doctors and nurses, which severely aﬀ ects health services, especially in some sub-Saharan African countries Employ less internationally mobile cadres Reward local employment with performance-related pay as in the successful Chinese national tuberculosis programme (requires good regulatory framework, skilled managerial resources, and careful monitoring to counter adverse eﬀ ects) Oﬀ er non-ﬁ nancial incentives—make staﬀ feel their work is valued and provide them with the capacity to work eﬀ ectively ● Use resource-allocation formulae to help ensure geographical equity ● Use ﬁ nancial incentives and subsidies to encourage uptake of priority interventions ● Provide information, tools, and training to help managers adapt services and resources to local disease burden—the experience of the Tanzania Essential Health Interventions Project shows the subsequent possible health gains be interpreted as statistical conﬁ dence intervals but evidence on which the estimates reported here are rather as a range of “best estimates” that incorporate variation across interventions in the cluster as well as In the ﬁ gures, intervention clusters are presented in geographical variation. Ranges for the cost-eﬀ ectiveness order of increasing (worsening) cost-eﬀ ectiveness ratios. ratios are also attributable to variations in the ratios of Observations about speciﬁ c clusters of interventions individual interventions in each group and in the epidemiological settings where the interventions were assessed. A population-based primary intervention in a Prevention and control of tuberculosis
low-prevalence area is usually less cost eﬀ ective than the Treatment of all forms of active tuberculosis with DOTS same intervention in a high-prevalence area. Figure 1 is am ong the most cost eﬀ ective of interventions shows interventions that deal with high-bu rden diseases, ($5–35 per DALY averted except in Europe and central and ﬁ gure 2 those that deal with relatively low-burden Asia). An internationally-recommended strategy, DOTS diseases. All results are in US$ discounted to the year has ﬁ ve components: political commitment; case 2001 at 3% yearly. No age weights are applied when detection by sputum smear microscopy, mostly among calculating DALYs. Chapter 2 of DCP2 provides a more self-referring symptomatic patients; standard short- complete discussion of cost-eﬀ ectiveness analysis course chemotherapy administered under proper case- guidelines provided to chapter authors and the quality of management conditions, including directly observed www.thelancet.com Vol 367 April 8, 2006
therapy; a system to ensure regular drug supplies; and a Panel 2: Development assistance for health
standard recording and reporting system, including the assessment of treatment outcomes. The BCG vaccination for children is also cost eﬀ ective ($40–170 per DALY ● Major health gains for the poor can be achieved relatively inexpensively by strategically averted) as a measure to reduce the burden in children of tuberculosis-associated meningitis and miliary tuber- ● Development assistance in health can be eﬀ ective with good policies in place even in culosis. Because BCG hardly aﬀ ects the huge burden of pulmonary tuberculosis in adults, development of a ● Development assistance in health can foster good policies and facilitate transition to new vaccine targeting adults is highly desirable. them—aid works better, the better the policy environment Treatment of latent tuberculosis in patients not coinfected with HIV is less cost eﬀ ective ($4000–25 000 ● Development partners and governments pursue major shifts in human resource and per DALY averted) than treatment of those who are budgetary allocations toward speciﬁ c high-payoﬀ investments in health coinfected ($16–230). Antiretroviral therapy for HIV/ ● Focus health-system development on a limited set of priority goals—controlling HIV/ AIDS is most cost eﬀ ective when used to extend the life AIDS, meeting health-related Millennium Development Goals, and controlling of patients who have been successfully treated for ● Design development assistance for health to reduce leakage to other sectors and lower Multidrug resistant tuberculosis (MDR-TB) is two to transaction costs—eg, using performance-based budget-support ten times more expensive to treat than drug-susceptible disease; prevention of its emergence and spread should be a priority. Management of MDR-TB with a fuels rapidly increasing HIV epidemics, harm-reduction standardised regimen, including second-line drugs, programmes, including clean needle exchanges, should costs about $70–450 per DALY averted. Individualised Prevention of mother-to-child transmission of HIV, combinations adjusted for each patient’s resistance using a single dose of nevirapine to both mother and pattern—are more costly but yield higher cure rates. As baby at birth, in generalised epidemic settings is both such, and though such treatment is harder to implement cost eﬀ ective and capable of averting great disease on a large scale, it could be as cost eﬀ ective as burden. Treatment of sexually transmitted infections to standardised treatment with regimens that use second- lower the risk of HIV transmission, although less well proven, also seems to be highly cost eﬀ ective ($16–105 Irrespective of resistance proﬁ le, management of tuberculosis in individuals with HIV requires higher investments than that needed for the basic directly observed treatment strategy. Nevertheless, the cost is Treatment of most opportunistic infections in people still typically less than $1 per day of healthy life gained— with HIV/AIDS is cost eﬀ ective ($10–500 per DALY a strong argument for integrating such interventions averted), and is becoming more so as an increasing into an enhanced tuberculosis control strategy. number of people receive antiretroviral treatment. Only a few studies17 have assessed the cost-eﬀ ectiveness of Prevention and treatment of HIV/AIDS
antiretroviral treatment, and these are limited to clinical Despite the scale and relentless growth of the HIV/ trials and not directly applicable to the resource-poor AIDS epidemic, cost-eﬀ ective interventions have been settings where use of antiretroviral treatment is developed for both prevention and treatment. increasing. Cost-eﬀ ectiveness is aﬀ ected by drug prices and adherence rates, and omits the non-health eﬀ ects of HIV/AIDS and the eﬀ ect of treatment on prevention Although remarkably little rigorous assessment has been of transmission. In settings where treatment costs are done, population-based programmes to prevent infection low and adherence rates high, antiretroviral treatment with HIV seem to be very cost eﬀ ective where prevalence is moderately cost eﬀ ective ($350–500 per DALY is high and the epidemic generalised beyond high-risk averted); however, treatment can be poor value for groups into the broader population. These programmes money if low adherence allows drug resistance to include peer-based education for high-risk groups, emerge and proliferate. How to achieve necessary including sex workers and injection drug users ($1–74 per adherence levels (80–90%) on a large scale at an DALY averted); voluntary testing and counselling aﬀ ordable cost in resource-poor settings is a research ($14–261); and social marketing, promotion, and distribution of condoms ($19–205). Programmes to improve the safety of blood and needles, although highly Illnesses and mortality in children
cost eﬀ ective ($4–51), avert only a limited burden of Mortality of neonates and of children younger than age disease in areas of generalised epidemics. In parts of 5 years can be greatly reduced at an aﬀ ordable cost, south, east, and central Asia, where injection drug use with interventions of proven eﬀ ectiveness in low- www.thelancet.com Vol 367 April 8, 2006
Panel 3: Research and development priorities
Unprecedented health gains in the past century resulted directly from knowledge gained through research, the development of new drugs, vaccines, and diagnostics, and improved technologies. Better, newer interventions to further reduce major causes of disease burden in low-income and middle-income countries are needed ● Convergence towards a predominance of non-communicable diseases in most regions of the world underscores need for greater research focus on cardiovascular diseases, cancer, diabetes, and neuropsychiatric conditions ● Continued threat of preventable communicable diseases, maternal mortality, and tropical diseases in sub-Saharan Africa and ● Emergence of potentially devastating pandemics, such as avian (H5N1) inﬂ uenza and obesity, as leading public-health concerns ● High burden of intentional and non-intentional injuries ● Many cost-eﬀ ective interventions do not yield their full potential for several reasons: Weak health systems, with limited infrastructure, and ﬁ nancial and human resources cient transfer of knowledge and technologies from one context to another Limited capacity for disease surveillance and disease modelling ● Discovery and approval of new and better dugs, vaccines, and diagnostics ● Improved understanding of major determinants and disease risk factors in various epidemiological, socioeconomic, and cultural ● Epidemiological surveillance at country level and worldwide ● Development of new and better intervention strategies that are locally appropriate and aﬀ ordable; this calls for stronger focus on developing treatment algorithms and guidelines, improved intervention packaging, better information about intervention costs and cost-eﬀ ectiveness, expanded delivery of health services, and well functioning health systems, as well as improved policy instruments ● Use results of cost-eﬀ ectiveness analyses to improve investment of limited resources ● Expand use of successful public-private partnerships for product development ● Do operational research on delivering important interventions that might rely on lifelong medication—eg, psychiatric disorders, HIV/AIDS, cardiovascular disease, and diabetes ● Identify health problems shared by industrialised and low-income and middle-income countries ● Increase potential of information technology ● Increase global health research capacity to attract and keep productive scientists in developing world ● Create a global health architecture that allocates a larger share of development assistance for health to research and development with a focus on neglected conditions income settings. Improvements are likely to follow an to preterm birth (27%), and asphyxia (23%). Intensive increase in coverage of preventive measures, such as care is not needed to save most of these babies. Low- breastfeeding, and expansion of childhood vaccination income countries—for instance, Sri Lanka—have programmes beyond the traditional six antigens in achieved neonatal mortality rates of 15 per 1000 without places where coverage is high and where new antigens intensive care; less than a third of the neonatal mortality address diseases of signiﬁ cant burden, particularly pneumococcal and Haemophilus inﬂ uenzae type b Inclusion of essential care for newborn babies (warmth, vaccines. Implementation and increased coverage of cleanliness, and immediate breastfeeding), neonatal curative interventions for acute respiratory infections, resuscitation, facility-based care of preterm babies, and malaria, and diarrhoea should reduce the ﬁ gure of 6 emergency care of ill neonates to the standard maternal million preventable deaths every year in this age and child health package has proven highly cost eﬀ ective in India ($11–265 per year of life saved, or $24–585 per DALY averted) and sub-Saharan Africa ($25–360 per year of life saved, or $46–657 per DALY averted); however, An estimated 4 million babies younger than age 28 days provision of such care depends on great initial investment. die every year, accounting for 38% of all deaths in Addition of community-based interventions—promoting children younger than age 5 years. Causes of death healthy behaviours, such as breastfeeding, providing include infections (36%, including neonatal sepsis, extra care of moderately small babies at home through pneumonia, diarrhoea, and tetanus), complications due clean liness, warmth, and exclusive breastfeeding, plus www.thelancet.com Vol 367 April 8, 2006
HIV/AIDS: treatment of Kaposi's sarcoma
Ischaemic heart disease: coronary artery bypass graft
Myocardial infarction: acute management with tissue plasminogen activator, with aspirin and β blocker
Tuberculosis (endemic, latent): isoniazid treatment
Diarrhoeal disease: improved water and sanitation at current coverage of amenities and other interventions
Diarrhoeal disease: cholera or rotavirus immunisation
Diabetes, ischaemic heart disease, and stroke: media campaign to reduce saturated fat
Stroke and ischaemic and hypertensive heart disease: polypill by absolute risk approach
Ischaemic heart disease: statin, with aspirin, β blocker, and ACE inhibitor
Stroke (ischaemic): acute management with heparin and recombinant tissue plasminogen activator
Diabetes, ischaemic heart disease, and stroke: legislation with public education to reduce salt content
Depression: drugs with optional episodic or maintenance psychosocial treatment
Alcohol misuse: 25–50% increase in excise tax rate
Diarrhoeal disease: oral rehydration therapy for package costing $5·50 per episode
Diarrhoeal disease: breastfeeding promotion
HIV/AIDS: antiretroviral therapy
Coronary artery disease: legislation substituting 2% of trans fat with polyunsaturated fat at $6 per adult
Ischaemic heart disease: aspirin, β blocker, with optional ACE inhibitor
HIV/AIDS: home care
Myocardial infarction: acute management with streptokinase, with aspirin and β blocker
Alcohol misuse: brief advice by primary health-care doctor
Alcohol misuse: excise tax, advertising ban, with brief advice
Myocardial infarction and stroke: secondary prevention with polypill
Alcohol misuse: advertising ban and reduced access to beverage retail
Lower acute respiratory infection (0–4 years): case management package at community, facility, and hospital levels
Tobacco addiction: nicotine replacement therapy
Tobacco addiction: non-price interventions*
Tuberculosis (endemic): management of drug resistance
Tuberculosis (endemic, infectious or non-infectious): directly observed short-course chemotherapy
Haemophilus inﬂuezae type B, hepatitis B, diphtheria, pertussis, and tetanus: pentavalent vaccine
Tuberculosis (epidemic): management of drug resistance
Tuberculosis (epidemic, latent): isoniazid treatment
HIV/AIDS: mother-to-child transmission prevention
Diarrhoeal disease: hand pump, standpost, or house connection where clean water supply is limited
HIV/AIDS: opportunistic infection treatment
Congestive heart failure: ACE inhibitor and β blocker, with diuretics
Stroke (ischaemic): acute management with aspirin
Diarrhoeal disease: construction and promotion of basic sanitation where facilities are limited
Problems requiring surgery: surgical ward or services in district hospital or community clinic
HIV/AIDS: tuberculosis coinfection prevention and treatment
Emergency care: staﬀed community ambulance
Tuberculosis (epidemic, infectious): directly observed short-course chemotherapy
HIV/AIDS: blood and needle safety
HIV/AIDS: condom promotion and distribution
Tuberculosis (endemic): BCG vaccine
HIV/AIDS: sexually transmitted infections diagnosis with treatment
Coronary artery disease: legislation substituting 2% of trans fat with polyunsaturated fat at $0·50 per adult
HIV/AIDS: voluntary counselling and testing
Diarrhoeal disease: water sector regulation with advocacy where clean water supply is limited
Underweight child (0–4 years): child survival programme with nutrition
Childhood illness: integrated management of childhood illness
HIV/AIDS: peer and education programmes for high-risk groups
Tobacco addiction: taxation causing 33% price increase
Malaria: intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine
Malaria: residual household spraying
Myocardial infarction: acute management with aspirin and β blocker
Malaria: insecticide-treated bed nets
Tuberculosis, diphtheria-pertussis-tetanus, polio, measles: traditional EPI
Malaria: intermittent preventive treatment in pregnancy with drugs other than sulfadoxine-pyrimethamine†
Emergency care: training volunteer paramedics with lay ﬁrst-responders
Diarrhoeal disease: hygiene promotion
Cost-eﬀectiveness ratio ($ per DALY averted) Figure 1: Cost-eﬀ ectiveness of interventions related to high-burden diseases in low-income and middle-income countries (>35 million DALYs)
Bars=range in point estimates of cost-eﬀ ectiveness ratios for speciﬁ c interventions included in each intervention cluster and do not represent variation across regions or statistical conﬁ dence intervals.
Point estimates obtained from DCP2, calculated as midpoint of range estimates reported, or calculated from a population-weighted average of region-speciﬁ c estimates reported. Only interventions
with cost-eﬀ ectiveness reported in terms of DALYs are included in ﬁ gure. *Advertising bans, smoking restrictions, supply reduction, and information dissemination. †Chloroquine=ﬁ rst line drug;
artemisinin-based combination therapy=second-line drug; and sulfadoxine-pyrimethamine=ﬁ rst-line or second-line drug.
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manage ment of acute respiratory infections—to the Africa and $2810 ($39 per DALY averted) in Latin maternal and child health package is likely to be highly cost eﬀ ective. A year of life saved could cost as little as Multivalent pneumococcal conjugate vaccines could $100–257 in India ($221–568 per DALY averted) and reduce the incidence of invasive pneumococcal disease $100–270 in sub-Saharan Africa ($183–493). These while lowering antibiotic use and the likelihood of drug approaches are feasible now in virtually all countries. resistance. At $50 per dose, however, these vaccines are Resuscitation of newborn children with a self-inﬂ ating unaﬀ ordable to most people in low-income and middle- bag that costs as little as $5 in low-income and middle- income countries. After conﬁ rmation of eﬃ income countries can save lives at low cost if a midwife sub sequent licensing, new vaccines that protect against is available. Provision of two tetanus toxoid immunisations rotavirus, malaria, human papilloma virus-associated to all pregnant women could avert more than cervical cancer, and dengue should be included in the 150 000 neonatal deaths every year. Improvement of maternal and child health services delivered through a combination of family-level and community-level care, outreach, and clinical care would increase the survival Although vaccination is essential, patients’ management rates of newborn and older children and reduce cient use of ﬁ nancial resources, although more demanding of health-system capacity. Management in the community or at a health-care facility might be Vaccine-preventable diseases in childhood comparably cost eﬀ ective, but community-based strate- Childhood vaccinations, long recognised as among the gies hold promise for more rapid coverage. Treatment most cost eﬀ ective uses of resources, prevented more of non-severe pneumonia at facilities with oral anti- than 3 million deaths worldwide in 2001. National microbials and paracetamol ($24–424 per DALY averted) immunisation programmes include vaccines against is slightly more cost eﬀ ective than similar treatment tuberculosis, diphtheria, tetanus, pertussis, polio- administered at home by a health-care worker myelitis, and measles at a cost per fully immunised ($139–733). Treatment of severe pneumonia in a hospital child of $13–24, depending on coverage levels and type rather than at home is more expensive ($1486–14 719). of delivery strategy (health-facility based, campaigns, or mobile teams outreach). The estimated cost per death averted varies from less than $275 (under $10 per DALY Of the interventions for diarrhoeal disease during the averted) in sub-Saharan Africa and south Asia to ﬁ rst year of life, breastfeeding promotion programmes $1754 ($20 per DALY averted) in Europe and central ($527–2001 per DALY averted), measles immunisation Asia. This pronounced variation is largely attributable ($257–4565), and oral rehydration therapy (as low as to diﬀ erences in the underlying prevalence of disease. $132, for a cost per child of $0·70) are relatively cost These same factors also aﬀ ect the cost-eﬀ ectiveness of eﬀ ective compared with rotavirus immunisations scaling up coverage with the traditional Expanded ($1402–8357) and cholera immunisations ($1658–8274). Program on Immunization (EPI) vaccines. The cost per Because great reductions in mortality from this death averted varies by region, from $162 in sub-Saharan condition have already been achieved, the average case Africa to more than $1600 in eastern Europe. Costs are fatality rate from diarrhoea is now much lower than less than $20 per DALY averted in all regions other than before oral rehydration therapy was introduced. Where Europe and central Asia. Cost-eﬀ ectiveness of the none of these interventions has been adopted, diarrhoeal tetanus toxoid vaccine also varies widely, from less than disease is still a major killer, and oral rehydration $400 per death averted ($14 per DALY averted) in sub- therapy and other measures are more cost eﬀ ective in Saharan Africa and south Asia to more than $190 000 preventing deaths even if diarrhoea incidence is ($15 000 per DALY averted) in Europe and central Asia.
unchanged. The situation is parallel to that for Including a second opportunity for measles vaccination immunisation: cost-eﬀ ectiveness might look poor through routine or campaign based approaches costs because of gains already achieved, but both continued $23–228 per death averted and less than $4 per DALY and expanded coverage are needed. Similarly, averted in developing regions other than Europe and improvements in water and sanitation ($1118–14901 per central Asia. New vaccines cost more per dose and are DALY averted from diarrhoeal disease) are less cost less cost eﬀ ective than the current EPI vaccines, but eﬀ ective where access to these amenities is adequate might be worth while in regions of high disease and other interventions against diarrhoeal disease exist. prevalence. The pent avalent vaccine (DPT–hepatitis In areas with little access to water and sanitation, B–Hib) has an estimated cost per death of $1433–40 000 however, improvements can be highly cost eﬀ ective and a cost-eﬀ ec tive ness of $42 per DALY averted in sub- because they reduce incidence of illness ($94 per DALY Saharan Africa and greater than $245 elsewhere. averted for installation of hand pumps and $270 per Addition of a yellow fever vaccine costs between $834 DALY averted for provision and promotion of basic per death averted ($26 per DALY averted) in sub-Saharan www.thelancet.com Vol 367 April 8, 2006
Parkinson's disease: levodopa or carbidopa with deep brain stimulation
Hepatitis B: vaccination
Schizophrenia: antipsychotic drugs with optional psychosocial treatment, hospital-based
Schizophrenia: antipsychotic drugs with optional psychosocial treatment, community-based
Trachoma: tetracycline or azithromycin treatments
Lower acute respiratory infection (0–4 years): case management of severe and very severe cases at hospital level
Bipolar disorder: lithium, valproate, with optional psychosocial treatment, hospital-based
Bipolar disorder: lithium, valproate, with optional psychosocial treatment, community-based
Epilepsy: second-line treatment of phenobarbital with lamotrigine or surgery
Dengue: vector control
Traﬃc accidents: enforcement of seatbelt laws, promotion of child restraints, and random driver breath testing
Stroke: secondary prevention with carotid endarterectomy
Tetanus: tetanus toxoid vaccination, mix of strategies
Parkinson's disease: ayurvedic treatment and levodopa or carbidopa
Panic disorder: drugs with optional psychosocial treatment
Haemophilus inﬂuenzae type B: H inﬂuenzae type B-containing vaccine
Dengue: improved case management
Undernutrition and malnutrition (0–4 years): sustained child health and nutrition package
Cataract: extracapsular surgery
Lower acute respiratory infection (0–4 years): case management of non-severe cases at community or facility level
Unwanted pregnancies: family planning programmes
Epilepsy: ﬁrst-line treatment with phenobarbital
Stroke: secondary prevention with aspirin and dipyridamole
Zinc deﬁciency (0–4 years): supplements with oral rehydration salts
Trachoma: trichiasis surgery
Adolescent health: school health and nutrition programmes
Onchocerciasis: treatment with ivermectin
Traﬃc accidents: increased speeding penalties, enforcement, media campaigns, and speed bumps
Down's syndrome: prenatal screening with option of pregnancy termination
Leishmaniasis: case ﬁnding with treatment
Measles: second opportunity vaccination in a ﬁxed facility
Soil-transmitted helminths: albendazole
Cost-eﬀectiveness ratio ($ per DALY averted) Figure 2: Cost-eﬀ ectiveness of interventions related to low-burden diseases in low-income and middle-income countries (<35 million DALYs)
Bars=range in point estimates of cost-eﬀ ectiveness ratios for speciﬁ c interventions included in each intervention cluster and do not represent variation across regions or statistical conﬁ dence intervals.
Point estimates obtained from DCP2, calculated as midpoint of range estimates reported, or calculated from a population-weighted average of region-speciﬁ c estimates reported. Only interventions
with cost-eﬀ ectiveness reported in terms of DALYs are included in ﬁ gure.
Integrated management of childhood illnesses eﬀ ective at preventing death in the ﬁ rst few years An integrated package, consisting of exclusive breast- ($8000–12 000 per death averted, or $300–400 per DALY feeding, vitamin A and zinc supplementation, screening averted). At $10 000 or more per DALY averted, however, for immunisation, and management of pneumonia, the repeated transfusions needed for some thalassaemias malaria, and diarrhoea—including oral rehydration are unaﬀ ordable to all but the rich in low-income and therapy—costs about $4·10 per child in sub-Saharan middle-income countries; bone-marrow transplant, Africa and is cost eﬀ ective ($38 per DALY averted) when seldom needed, costs even more. A strategy that worked in coverage is at least 50%. Constant attention to quality is Cyprus, Greece, and Italy, countries with previously high especially important when introducing packages of diverse incidence rates of thalassaemias, involved the screening of couples to ascertain their risk of having an aﬀ ected child, followed by prenatal testing—a relatively expensive Inherited disorders of haemoglobin proposition—only of couples at high risk. Inherited disorders of haemoglobin, including sickle cell anaemia and the thalassaemias, aﬀ ect about 500 000 Tropical diseases
babies every year and have a high mortality rate. Expensive Despite health researchers’ neglect of predominantly prenatal screening for sickle cell disease can be replaced tropical diseases, interventions to control—and in some by much cheaper screening of newborn babies and by cases eliminate—these diseases rank among the most counselling. Antibiotic prophylaxis is moderately cost www.thelancet.com Vol 367 April 8, 2006
(Ascaris lumbricoides, Trichuris trichuria, and hookworm) Prevention and eﬀ ective treatment options of this disease with albendazole costs $2–9 per DALY averted. Although are highly cost eﬀ ective and can yield large health gains in the cost of treating schistosomiasis with praziquantel is areas where malaria is endemic. Methods of prevention much higher ($336–692), a combination of albendazole include insecticide-treated bednets ($5–17 per DALY and praziquantel is extremely cost eﬀ ective ($8–19).
averted) and indoor residual spraying with DDT, malathion, deltamethrin, or cyhalothrin ($9–24 per DALY Reproductive health
Given the hugely disproportionate burden of maternal Intermittent preventive treatment of malaria during and neonatal deaths in low-income and middle-income pregnancy, using sulfadoxine-pyrimethamine, is a highly countries,6 identifying aﬀ ordable, easy-to-implement cost-eﬀ ective ($13–24 per DALY averted) means of preventive interventions is a priority. Improved primary- reducing neonatal mortality, mainly from low birth weight, level coverage with a package of prenatal and delivery and severe maternal anaemia. Changing of ﬁ rst-line care is very cost eﬀ ective in lowering both maternal and treatment for malaria from chloroquine, an ineﬀ ective perinatal deaths ($3337–6129 per death averted and drug in much of the world, to an artemisinin-based $92–148 per DALY averted) as are improvements in combination oﬀ ers faster cures and potential reductions quality of prenatal and delivery care ($2729–5107 per in transmission, with cost-eﬀ ectiveness of better than death averted and $82–142 per DALY averted). Notably, $150 per DALY averted. A change to sulfadoxine- improving the quality of care and expanding coverage are pyrimethamine might be slightly more cost eﬀ ective initially because this drug costs less than artemisinin-based combinations; however, this advantage would Nutrition
probably be eroded quickly because of the expected rapid Direct and indirect eﬀ ects of undernutrition and micronutrient deﬁ ciencies account for about a third of the disease burden in low-income and middle-income Lymphatic ﬁ lariasis, onchocerciasis, and Chagas’ disease countries.18 Interventions to prevent malnutrition, such Yearly drug administration to the entire population at risk as breastfeeding support programmes ($3–11 per DALY for long enough to interrupt transmission represents a averted and $100–300 per death averted) and growth cost-eﬀ ective way to eliminate lymphatic ﬁ lariasis in high monitoring and counselling ($8–11 per DALY averted), prevalence areas ($4–8 per DALY averted). An alternative are moderately cheap. Large-scale community health and is to fortify salt with diethylcarbamazine ($1–3) and to use nutrition programmes that promote such inter ventions and better child feeding practices can reduce stunting— Onchocerciasis control programmes have been highly and the sequelae of cognitive impairment, increased successful in west Africa: investigators estimate the cost- susceptibility to obesity, and later chronic disease—by an eﬀ ectiveness of community-directed ivermectin treatment additional 1–2 percentage points per year at an annual at roughly $7 per DALY averted when the drug is provided cost of $5–10 per child or $200–250 per DALY averted, free of charge. The cost of vector control to prevent—and often without the need for additional food. Micronutrient perhaps eliminate—Chagas’ disease is about $260 per intake can be supplemented with capsules or by fortifying sugar, salt, water, or other essentials. For vitamin A deﬁ ciencies, capsule distribution ($6–12 per DALY Leishmaniasis and African trypanosomiasis averted) is more cost eﬀ ective than sugar fortiﬁ cation Intervention opportunities exist even for tropical diseases ($33–35), especially where the prevalence of vitamin A for which control measures are less eﬀ ective. Improved deﬁ ciency is low. Fortiﬁ cation of salt, sugar, and cereal to management of patients with dengue ($587 per DALY correct iron deﬁ ciency and of water and salt to correct averted) is more cost eﬀ ective than environmental iodine deﬁ ciency is less expensive than distributing management or insecticides (more than $2000). Treatment supplements for mild deﬁ ciency, though pregnant women for leishmaniasis is extremely cost eﬀ ective ($315 per and severely anaemic or iodine-deﬁ cient people might still death averted and $9 per DALY averted), as is treating need to take a supplement. Overall cost-eﬀ ectiveness is patients with African trypanosomiasis in the second stage $66–70 per DALY averted for iron fortiﬁ cation and $34–36 of the disease, using melarsoprol or eﬂ ornithine ($10–20 per DALY averted for iodine fortiﬁ cation.
Cancer prevention and treatment
Initial treatment costs between $1300 and $6200 per year Helmintic infections, although not a great cause of death of life saved for the more treatable cancers of the cervix, in tropical regions, have a great eﬀ ect on wellbeing, breast, oral cavity, colon, and rectum, and between $53 000 growth, and physical ﬁ tness, and on school attendance, and $163 000 per year of life saved for less treatable liver, worker productivity, and earning potential. Mass school- lung, stomach, and oesophagus cancers. Postmastectomy radiation might be cost eﬀ ective in developing countries, www.thelancet.com Vol 367 April 8, 2006
where the cost of treatment can be lower than in developed medications with fewer side-eﬀ ects and potentially countries. Palliative care for terminally ill patients is a greater compliance (an advantage for long-term use)— challenge, especially where opioid drugs, a cost-eﬀ ective for example ﬂ uoxetine, a generic selective serotonin reuptake inhibitor (SSRI)—increases costs ($1229–2459 Biennial screening by clinical breast examination is per DALY averted). Finally, the treatment of panic estimated to be cost eﬀ ective at $552 per life-year saved for disorder with tricyclic antidepressants ($305–619) and women from age 40–60 years, indicating the large SSRIs ($567–865) is more cost eﬀ ective than treatment proportion of tumours with a poor prognosis in developing with tricyclic antidepressants combined with psychosocial countries. In this setting, clinical breast examination is interventions. Psychosocial treatment without drugs is more cost eﬀ ective than mammography: mammograms comparably cost eﬀ ective ($338–927). every 2 years save 10% more life-years than yearly clinical Tricyclic antidepressants are more cost eﬀ ective than breast examination, but the cost is more than 100% higher. benzodiazepines, which are still often prescribed for As with any screening programme, cost-eﬀ ectiveness is anxiety disorders and produce dependence in many greater with higher underlying prevalence.
patients. A package of mental-health interventions to address all four disorders costs between $1429 and $2902 Mental and neurological disorders
per DALY averted, depending on the region.
Mental disorders are heterogeneous conditions that vary considerably in intervention cost and associated burden Parkinson’s disease and epilepsy reduction. Treatments for depression are much more cost Traditional Indian ayurvedic treatment is relatively cost eﬀ ective in general than are those for bipolar disorder and eﬀ ective for Parkinson’s disease ($750 per DALY averted) schizophrenia. For the latter two disorders, the potentially compared with a combination of levodopa and carbidopa great beneﬁ ts to family members and to society as a whole ($1500) to treat the debilitating symptoms and delay the are not captured by DALYs and should be balanced against progress of the disease, or deep-brain stimulation the relatively high cost of improving health for some individuals. For many disorders, drugs are eﬀ ective, especially when combined with psychosocial treatment, phenobarbital to help control seizures ($89 per DALY including group therapy, family interventions, and averted)—but few eligible patients receive treatment. cognitive-behavioural approaches to managing symptoms Options such as lamotrigine or surgery are signiﬁ cantly and improving adherence to medications. Stigma is a less cost eﬀ ective than phenobarbital for ﬁ rst-line major challenge, for which creative interventions are treatment; however, they are cost eﬀ ective for the small proportion of patients who do not respond to phenobarbital. The emphasis must be on extending treatment with Schizophrenia and bipolar disorder phenobarbital to the many who do not receive it.
Community-based drug treatment accompanied by psychosocial treatment is the most cost-eﬀ ective approach Prevention and treatment of cardiovascular disease
for these severe mental disorders. Newer antipsychotic Cardiovascular diseases, including ischaemic heart disease, and mood-stabilising drugs have become less expensive; congestive heart failure, and stroke, account for more than even so, they are less cost eﬀ ective than drugs that have a quarter of all deaths in low-income and middle-income been available for a while. A combination of haloperidol countries; treatment is likely to account for an increasing and family psychoeducation is typically much more cost proportion of health-care expenditure in these countries. eﬀ ective ($1743–4847 per DALY averted) than a combination of a new antipsychotic drug (risperidone) Population-based primary prevention with family psychoeducation ($10 232–14 481) in the Interventions to modify lifestyles can eﬀ ectively lower treatment of schizophrenia. For bipolar aﬀ ective disorder, the risk of coronary artery disease and stroke at a family psychoeducation is more cost eﬀ ective when moderately low cost without expensive health combined with the older medication lithium ($1587–4928 infrastructure. Replacing dietary trans fat with per DALY averted) than with valproate ($2765–5908). polyunsaturated fat is likely to be eﬀ ective in settings where trans fat intake is high. If such replacement occurs during manufacture rather than through changes in Treatment for the more common disorders of depression individual behaviour, the cost would be $25–73 per DALY and anxiety is more cost eﬀ ective than treatment for the more severe disorders; interventions are less expensive monounsaturated fat in manufactured foods accompa- and the reduction in disability is greater. For depression, nied by a public education campaign is relatively drug therapy with tricyclic antidepressants (imipramine expensive ($1865–4012 per DALY averted), although the or amitriptyline) costs $478–1288 per DALY averted. cost per DALY averted is highly sensitive to the relative Management of chronic depression to reduce relapses risk reduction in cardiovascular events as well as the cost is similarly cost eﬀ ective ($749–1760). Use of newer per individual. Reduction of salt levels in manufactured www.thelancet.com Vol 367 April 8, 2006
foods through a combination of legisla tion and education to be at high risk for subsequent ischaemic heart disease, campaigns is also expensive ($1325–3056 per DALY it will generally make sense to use more than aspirin for averted), but could be much more cost eﬀ ective in secondary prevention. The combination of the antiplatelet populations with a high salt intake. Little evidence is medication dipyridamole and aspirin is equally cost available on the cost-eﬀ ectiveness of programmes to eﬀ ective ($93 per DALY averted). By contrast, carotid encourage exercise and other behavioural changes.
endarterectomy is a costly option for secondary prevention ($1500 per DALY averted).
Personal interventions Prevention strategies targeted at individuals at high risk Strategies for injury prevention
for cardiovascular disease—measured as a combination Economic development and increased motor vehicle use of non-optimal blood pressure, poor lifestyle, poor nutrition, tobacco and alcohol use, and genetic risk these events account for roughly a third of the burden factors—can be eﬀ ective, especially when implemented from all unintentional injuries in low-income and in tandem with population-based measures. A previous cardiovascular event reliably predicts a second event. Speed bumps are the most cost eﬀ ective method of Single-pill combinations of blood pressure-lowering prevention, costing less than $5 per DALY averted in all medications, statins, and aspirin oﬀ er the dual beneﬁ t of regions if installed at the most dangerous junctions that lowering the risk of cardiovascular disease and facilitating account for 10% of junction-related deaths. Increased compliance with the drug regimen. A hypothetical speeding penalties, media coverage, and enforcement of multidrug regimen, including aspirin, a β blocker, a c laws are only slightly less cost eﬀ ective. Motorcycle thiazide diuretic, an angiotensin-converting-enzyme helmet legislation ($467 per DALY averted in Thailand), (ACE) inhibitor, and a statin might be implemented at a bicycle helmet legislation ($107 per DALY averted in cost of $721–1065 per DALY averted compared with no China), and improved enforcement of traﬃ treatment in a population with an underlying 10-year risk through a combination of policing and information of cardiovascular disease of 35%. The use of a multidrug campaigns ($5–169 per DALY averted) cost more, but regimen for prevention in patients with a lower deserve greater attention, given the growing health underlying risk improves health beneﬁ ts, but costs burden associated with rising vehicle ownership. Seat belts and child restraints are eﬀ ective in the developed world; lowering their costs and encouraging their routine Acute management of cardiovascular disease use should improve cost-eﬀ ectiveness in low-income and The cost of treating acute myocardial infarction with aspirin and β blockers is less than $25 per DALY averted Interventions to reduce intentional violence, both self- in all regions. Relatively more expensive interventions inﬂ icted (suicides) and interpersonal (homicides and war- that oﬀ er marginally greater eﬀ ectiveness include related deaths), include changing cultural norms, thrombolytics, such as streptokinase ($630–730 per DALY reducing access to guns and deadly pesticides, and averted), and tissue plasminogen activator ($16 000). improving criminal justice and social welfare systems, In regions with poor access to hospitals, a combination of aspirin plus the β blocker atenolol is highly cost eﬀ ectiveness framework, and a cost-beneﬁ t analysis is eﬀ ective in preventing the recurrence of a vascular event more appropriate. Findings of studies in developed ($386–545 per DALY averted). The incremental cost- countries show that behavioural, legal, and regulatory eﬀ ectiveness of sequentially adding an ACE inhibitor interventions cost less than the money they save, in some such as enalapril ($660–866), a statin such as lovastatin cases by an order of magnitude. Provision of shelters for ($1700–2000), and coronary artery bypass graft (more victims of domestic violence in the USA results in a than $24 000 per DALY averted) to the baseline therapy is beneﬁ t–cost ratio of 6·8–18·4 to one. Interventions for less favourable. In all regions, treating congestive heart troubled young people to reduce criminal activity include failure with enalapril and the β blocker metoprolol is also mentoring (with net beneﬁ ts ranging from $231 to $4651 highly cost eﬀ ective (about $200 per DALY averted).
per participant), family therapy ($14 545–60 721), and aggression replacement therapy ($8519–34 071). Acute management and secondary prevention of strokeTreatment of acute ischaemic stroke with aspirin costs Conditions that require surgery
$150 per DALY averted. The use of a tissue plasminogen Types of surgery that are highly cost eﬀ ective include care activator ($1300) and anticoagulants such as heparin or to injury victims (eg, those with head trauma and burns); warfarin ($2700) is relatively cost ineﬀ ective. Aspirin is handling of obstetric complications (eg, obstructed labour the cheapest option for secondary prevention of ischaemic or haemorrhage); and elective surgery for conditions that stroke ($3·80 per single percentage point decrease in the seriously aﬀ ect quality of life (eg, cataracts and otitis risk of a second stroke within 2 years, or $70 per DALY media). In areas of high prevalence, cataract surgery can averted). Since having had a stroke indicates an individual be highly cost eﬀ ective (about $100 per DALY averted). www.thelancet.com Vol 367 April 8, 2006
Many surgical interventions—resuscitation and airway priority, addressed eﬀ ectively through random breath management with simple procedures such as chest tubes testing and stricter enforcement of drink-driving laws and tracheostomy, and management of fractures and of ($531 per DALY averted). Provision of brief advice to high- burns covering less than 30% of the body—require only risk drinkers by a primary care physician is of intermediate the facilities oﬀ ered by district hospitals. The quality of cost-eﬀ ectiveness ($480–819) in all regions; combining surgery and the risk of complications vary widely, and this advice with a tax on alcohol should improve cost- adequate health-service capacity is an important eﬀ ectiveness ($260–533), except in sub-Saharan Africa.
consideration. For the typical surgical facility in a district hospital in a low-income or middle-income country, the Delivering interventions
average cost per DALY averted for a representative set of Interventions are rarely freestanding, but are delivered surgical procedures is between $70 and $230. General through a service infrastructure. Community health status surgery at a district hospital is cost eﬀ ective in south Asia is correlated with the quality of health-service facilities, and sub-Saharan Africa because of low infrastructure costs which can be enhanced even in resource-constrained and high avertable disease burden. Surgical interventions settings, with greatest potential for improving quality at with poor cost-eﬀ ectiveness include ﬁ rst-line treatment of low cost. Intervention and service quality greatly aﬀ ect epilepsy, which helps only patients who are resistant to cost-eﬀ ectiveness, and improving quality can be an eﬃ drug treatment, and percutaneous transluminal coronary use of resources. Improvement of the quality of care of angioplasty for cardiovascular events.
acute respiratory infections through an educational activity for providers costs from $132–$800 per life saved ($4–28 Alcohol and tobacco use
per DALY averted) when initial intervention quality is poor The growing prevalence of smoking, especially in women and infections are widespread. Quality improvements cost in low-income and middle-income countries, seriously $2000–5000 per life saved ($70–176 per DALY averted) with threatens health. Interventions to reduce tobacco use are better baseline quality, low disease prevalence, or both. not only highly cost eﬀ ective, but they can avert a large Educational interventions to improve treatment for burden of deaths. Tobacco tax increases often increase tax diarrhoea can be extremely cost eﬀ ective (less than $18 per revenues as well as discouraging smoking initiation and DALY averted), depending on these two factors.
encouraging smokers to quit. The cost-eﬀ ectiveness of In DCP2, cost-eﬀ ectiveness analysis was done not just increasing cigarette prices by 33% ranges from $13 to $195 of speciﬁ c interventions, but also for levels of care (eg, per DALY averted globally, with a better cost-eﬀ ectiveness primary care, district hospitals, surgery). Evidence ratio ($3–42 per DALY averted) in low-income countries. suggests that it is highly cost eﬀ ective to develop a well Nicotine replacement therapy ($55–751) and non-price functioning general primary-care system, encompassing inter ventions, including banning advertising, pro viding local–district hospital levels, which can address up to 90% health education information, and forbidding smoking in of health-care demand in developing countries. public places, are relatively less cost eﬀ ective ($54–674) in The cost per death averted of training lay ﬁ rst-responders low-income countries, but still belong in any tobacco to emergencies and volunteer paramedics is between control programme. Compre hensive tobacco control $130 and $283 ($5–11 per DALY averted), depending on programmes that use price and non-price interventions, the region. Ambulances equipped with trained paramedics and which aim speciﬁ cally to help the current 1·1 billion can avert deaths at a cost of $1148–3479 ($46–137 per smokers quit, should be increasingly implemented, DALY averted) in urban settings and $3457–10 449 especially now that more than 110 countries have adopted ($140–410) in rural settings. Evidence about district and the global Framework Convention on Tobacco Control.
referral hospitals is limited, but indicates that basic Where high-risk alcohol use is prevalent—especially in district-level hospital care could be highly cost eﬀ ective Europe and central Asia, Latin America and the Caribbean, and sub-Saharan Africa—tax increases to lower alcohol Strengthening of referral hospitals has various beneﬁ ts use are very cost eﬀ ective ($105–225 per DALY averted). cult to quantify, including providing more Where high-risk use is less prevalent—east Asia and the complex clinical care to referred cases, disseminating Paciﬁ c and south Asia—tax-based policies can be among appropriate health technologies, and lending clinical, the least cost-eﬀ ective inter ventions (more than $2500 per managerial, and administrative support to other health- DALY averted). Advertising bans are among the most cost-eﬀ ective of all interventions to reduce high-risk drinking in all regions ($134–280). In east Asia and the Strengthening health systems
Paciﬁ c, a comprehensive ban on advertising and reduced Cost-eﬀ ectiveness data for interventions and packages access to retail outlets are highly cost-eﬀ ective inter- indicate what a reasonably well functioning health system ventions ($123–146). In many regions, random breath can achieve. They represent potential cost-eﬀ ectiveness testing is one of the least cost-eﬀ ective interventions and need to be supplemented with evidence and guidance ($973–1856); however, in southeast Asia, averting the on how health systems can provide interventions burden associated with drink driving is an important ciently, and equitably. Although we have www.thelancet.com Vol 367 April 8, 2006
dealt mainly with the chapters in DCP2 that deal with Acknowledgments
intervention selection, one of the chapters in the book We are grateful to the many institutions, especially the four provides a more extended summary of ﬁ ndings institutional sponsors of DCPP, the Fogarty International Center of the US National Institutes of Health, the World Bank, WHO, and the concerning health systems.19 Panel 1 summarises the key Bill & Melinda Gates Foundation, and close to 1000 individuals on points in this chapter. To accelerate progress towards the whose eﬀ orts this paper is based. Advice and review for DCPP was health-related Millennium Development Goals and organised by the Inter Academy Medical Panel and the Institute of ensure that the poor are not left behind requires new Medicine of the US National Academy of Sciences. For this we express our gratitude to David Challoner, Guy de Thé, Patrick Kelley, and thinking about eﬀ ective service delivery for priority Jaime Sepúlveda. Pamela Maslen, Nancy Hancock, Candice Byrne, interventions. Human resources for health is one of the Andrew Marshall, and Mantra Singh provided invaluable biggest challenges that faces health systems. References
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17 Creese A, Floyd K, Alban A, Guinness L. Cost-eﬀ ectiveness of HIV/ Conﬂ ict of interest statement
AIDS interventions in Africa: a systematic review of the evidence. We declare that we have no conﬂ ict of interest.
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Reglur um aðgangsstýringu, akstur og umferð um Reykjavíkurflugvöll Orðskýringar og gildissvið Reglur þessar gilda um akstur, umferð og aðgang að flugsvæði Reykjavíkurflugvallar og að sérstökum starfssvæðum, eins og þau eru afmörkuð í fylgiskjali 1 með reglum þessum. Ákvæðum reglna þessara verður ekki beitt gagnvart flugverjum og flugfarþegum í flutningaf