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SUMMARYVaricella-zoster virus causes chickenpox (CP) and after reactivation herpes zoster (HZ). Vaccines are available against both diseases warranting an assessment of the pre-vaccination burden of disease. We collected data from relevant Belgian databases and performed five surveys of CP and HZ patients. The rates at which a general practitioner is visited at least once for CP and HZ are 346 and 378/100 000 person-years, respectively. The average CP and HZ hospitalization rates are 5·3 and 14·2/100 000 person-years respectively. The direct medical cost for HZ is about twice as large as the direct medical cost for CP. The quality-adjusted life years lost for ambulatory CP patients consulting a physician is more than double that of those not consulting a physician (0·010vs. 0·004). In conclusion, both diseases cause a substantial burden in Belgium.

Aim To assess the cost-effectiveness of vaccinating all or subgroups of adults aged 60 to 85 years against herpes zoster. Methods A deterministic compartmental static model was developed (in freeware R), in which cohorts can acquire herpes zoster according to their age in years. Surveys and database analyses were conducted to obtain as much as possible Belgian age-specific estimates for input parameters. Direct costs and Quality-Adjusted Life-Year (QALY) losses were estimated as a function of standardised Severity Of Illness (SOI) scores (i.e. as a function of the duration and severity of herpes zoster disease). Results Uncertainty about the average SOI score for a person with herpes zoster, the duration of protection from the vaccine, and the population that can benefit from the vaccine, exerts a major impact on the results: under assumptions least in favour of vaccination, vaccination is not cost-effective (i.e. incremental cost per QALY gained >48,000 for all ages considered) at the expected vaccine price of 90 per dose. At the same price, but under assumptions most in favour of vaccination, vaccination is found to be cost-effective (i.e. incremental cost per QALY gained

Background Despite the existence of varicella vaccine, many developed countries have not introduced it into their national schedules, partly because of concerns about whether herpes zoster (HZ, shingles) will increase due to a lack of exogenous boosting. The magnitude of any increase in zoster that might occur is dependent on rates at which adults and children mix – something that has only recently been quantified – and could be reduced by simultaneously vaccinating older individuals against shingles. This study is the first to assess the cost-effectiveness of combined varicella and zoster vaccination options and compare this to alternative programmes. Methods and findings The cost-effectiveness of various options for the use of varicella–zoster virus (VZV) containing vaccines was explored using a transmission dynamic model. Underlying contact rates are estimated from a contemporary survey of social mixing patterns, and uncertainty in these derived from bootstrapping the original sample. The model was calibrated to UK data on varicella and zoster incidence. Other parameters were taken from the literature. UK guidance on perspective and discount rates were followed. The results of the incremental cost-effectiveness analysis suggest that a combined policy is cost-effective. However, the cost-effectiveness of this policy (and indeed the childhood two-dose policy) is influenced by projected benefits that accrue many decades (80–100 years or more) after the start of vaccination. If the programme is evaluated over shorter time frames, then it would be unlikely to be deemed cost-effective, and may result in declines in population health, due to a projected rise in the incidence of HZ. The findings are also sensitive to a number of parameters that are inaccurately quantified, such as the risk of HZ in varicella vaccine responders. Conclusions Policy makers should be aware of the potential negative benefits in the first 30–50 years after introduction of a childhood varicella vaccine. This can only be partly mitigated by the introduction of a herpes zoster vaccine. They have to decide how they value the potential benefits beyond this time to consider childhood vaccination cost effective.

Rotavirus (RV) is the leading cause of severe gastroenteritis in children under 5 years of age. In this chapter we will document the burden of rotavirus gastroenteritis in the 27 countries of the European Union. Data on rotavirus disease burden is lacking for about half of the countries of the European Union. The available data for the other half show differences that do not necessarily reflect country-specific differences, but that may also be due to differences in study characteristics and quality. Based on the available literature, the annual incidence of RV disease in the European Union ranges from 0.064.15% of the children aged

A cost-effectiveness analysis of rotavirus vaccination in Belgium, England and Wales, Finland, France and the Netherlands published in 2009 was updated based on recent studies on rotavirus burden of disease and vaccine efficacy. All the qualitative conclusions in the previous study were found to remain valid. Vaccination remains cost-effective in Finland only when using plausible tender prices.

Background We conducted for the first time a systematic review, including a meta-analysis, of the incidence of symptomatic rotavirus (RV) infections, because (1) it was shown to be an influential factor in estimating the cost-effectiveness of RV vaccination, (2) multiple community-based studies assessed it prospectively, (3) previous studies indicated, inconclusively, it might be similar around the world. Methodology Pubmed (which includes Medline) was searched for surveys assessing prospectively symptomatic (diarrheal) episodes in a general population and situation, which also reported on the number of the episodes being tested RV+ and on the persons and the time period observed. A bias assessment tool was developed and used according to Cochrane guidelines by 4 researchers with different backgrounds. Heterogeneity was explored graphically and by comparing fits of study-homogenous ‘fixed effects’ and -heterogeneous ‘random effects’ models. Data were synthesized using these models. Sensitivity analysis for uncertainty regarding data abstraction, bias assessment and included studies was performed. Principal Findings Variability between the incidences obtained from 20 studies is unlikely to be due to study groups living in different environments (tropical versus temperate climate, slums versus middle-class suburban populations), nor due to the year the study was conducted (from 1967 to 2003). A random effects model was used to incorporate unexplained heterogeneity and resulted in a global incidence estimate of 0.31 [0.19; 0.50] symptomatic RV infections per personyear of observation for children below 2 years of age, and of 0.24 [0.17; 0.34] when excluding the extreme high value of 0.84 reported for Mayan Indians in Guatemala. Apart from the inclusion/exclusion of the latter study, results were robust. Conclusions/Significance Rather than assumptions based on an ad-hoc selection of one or two studies, these pooled estimates (together with the measure for variability between populations) should be used as an input in future cost-effectiveness analyses of RV vaccination.

Cost-effectiveness analyses are usually not directly comparable between countries because of differences in analytical and modelling assumptions. We investigated the cost-effectiveness of rotavirus vaccination in five European Union countries (Belgium, England and Wales, Finland, France and the Netherlands) using a single model, burden of disease estimates supplied by national public health agencies and a subset of common assumptions. Under base case assumptions (vaccination with Rotarix, 3% discount rate, health care provider perspective, no herd immunity and quality of life of one caregiver affected by a rotavirus episode) and a cost-effectiveness threshold of euro30,000, vaccination is likely to be cost effective in Finland only. However, single changes to assumptions may make it cost effective in Belgium and the Netherlands. The estimated threshold price per dose for Rotarix (excluding administration costs) to be cost effective was euro41 in Belgium, euro28 in England and Wales, euro51 in Finland, euro36 in France and euro46 in the Netherlands.

Many ectothermic animals are subject to fluctuating environmental temperatures during incubation as well as post-birth. Numerous studies examined the effects of incubation temperature or ambient temperature on various aspects of offspring phenotype. We investigated whether incubation temperature and ambient temperature have an interactive effect on offspring performance. Our study animal, the ectothermic vertebrate Lampropholis delicata (common garden skink; De Vis 1888), experiences fluctuating environmental temperatures caused by differential invasion of an exotic plant Vinca major (blue periwinkle). In the laboratory, eggs from wild-caught females were assigned to different incubation temperatures that mimicked variation in natural nests. The feeding performance and digestion time of each hatchling was tested at ambient temperatures that represented environ- ments invaded to different degrees by periwinkle. Incubation and ambient temperature interacted to affect a lizard's mobility, the time that it took to capture, subdue and handle a prey, and the number of handling 'errors' that it made while foraging. For a number of these characteristics, incubation-induced changes to a lizard's mass significantly affected this relationship. Irrespective of size, no interaction effect was found for digestion time: lizards digested food faster at warmer temperatures, regardless of incubation temperature. Thus, temperatures experienced during incubation may alter an animal's phenotype so that the surrounding thermal environment differentially affects aspects of feeding performance. Our results also demonstrate that incubation environment can induce changes to morphology and behaviour that carry over into a lizard's early life, and that in some cases these differences in phenotype interact to affect performance.We suggest that the immediate removal of exotic plants as part of a weed control strategy could have important implications for the foraging performance, and presumably fitness, of ectothermic animals.

This is one of the first studies to (1) describe the out-of-hospital burden of influenza-like-illness (ILI) and clinically diagnosed flu, also for patients not seeking professional medical care, (2) assess influential background characteristics, and (3) formally compare the burden of ILI in patients with and without a clinical diagnosis of flu. A general population sample with recent ILI experience was recruited during the 2011-2012 influenza season in Belgium. Half of the 2250 respondents sought professional medical care, reported more symptoms (especially more often fever), a longer duration of illness, more use of medication (especially antibiotics) and a higher direct medical cost than patients not seeking medical care. The disease and economic burden were similar for ambulatory ILI patients, irrespective of whether they received a clinical diagnosis of flu. On average, they experienced 5-6 symptoms over a 6-day period; required 1.6 physician visits and 86-91% took medication. An average episode amounted to is an element of 51-is an element of 53 in direct medical costs, 4 days of absence from work or school and the loss of 0.005 quality-adjusted life-years. Underlying illness led to greater costs and lower quality-of-life. The costs of ILI patients with clinically diagnosed flu tended to increase, while those of ILI patients without clinically diagnosed flu tended to decrease with age. Recently vaccinated persons experienced lower costs and a higher quality-of-life, but this was only the case for patients not seeking professional medical care. This information can be used directly to evaluate the implementation of cost-effective prevention and control measures for influenza. In particular to inform the evaluation of more widespread seasonal influenza vaccination, including in children, which is currently considered by many countries.

This study aims to explore irregular relationships between input and outcomes in cost-effectiveness analysis, accounting for interdependencies between many input parameters. We used a dynamic infectious disease transmission model investigating the cost-effectiveness of varicella and zoster vaccination as a case study. Incremental costs and effects were used separately as the outcomes of interest, rather than the ratio between these, and a single R 2 was calculated for groups of interdependent input parameters. Partial R 2 was obtained as measure for the marginal proportion of variance explained. The most important input parameters were related to zoster epidemiology and disease transmission. In case of linear relationships, R 2 is an easy to obtain importance measure, also in the presence of interdependent input parameters.

Purpose: Exposure to air pollution has been shown to be a trigger of acute myocardial infarction (AMI). As in those studies no correction was made for other meteorological factors, the present study wants to evaluate the independent environmental triggers of AMI. Methods: Weekly counts of AMI patients that underwent primary percutaneous coronary intervention (pPCI) in the period 2006-2009 in 32 Belgian PCI centres were extracted from the national PCI database. Those data were correlated with average weekly meteorological data obtained from daily measurements in 73 meteorological sites, equally distributed in Belgium. The following meteorological measures were investigated: air pollution expressed as particulate matter both less than 10μM (PM10) and less than 2.5μM (PM2.5), black smoke, temperature and relative humidity. Time-series and Poisson regression analysis were carried out to investigate the correlation between environmental changes and the incidence of AMI. Results: During the study period a total of 15964 AMI patients (mean age 63, 24.8% female) were admitted with a weekly average admission rate of 77±11 patients. Time-series (see figure) and univariate Poisson regression revealed a significant positive correlation between AMI's and air pollution and an inverse correlation between AMI's and temperature. Multivariate analysis showed that only low temperature was significantly correlated with AMI with an increase of 7% AMI's for each 10°C decrease in minimal temperature (0R 1.07 95% CI 1.04-1.11.) and that there was no significant effect of air pollution (0R 1.01 95% CI 1.00-1.02). ![Figure][1] time series Conclusions: In a global environmental model, low temperature is by far the most important environmental trigger for AMI, whereas air pollution has a negligible effect. [1]: pending:yes