Imperial College London

DrHugoTurner

Faculty of MedicineSchool of Public Health

Lecturer
 
 
 
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hugo.turner Website

 
 
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UG 3 (Praed street side)Medical SchoolSt Mary's Campus

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Summary

 

Publications

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73 results found

Turner H, Archer R, Downey L, Isaranuwatchai W, Chalkidou K, Jit M, Teerawattananon Yet al., 2021, An introduction to the main types of economic evaluations used for informing priority setting and resource allocation in healthcare: key features, uses and limitations, Frontiers in Public Health, Vol: 9, Pages: 1-17, ISSN: 2296-2565

Economic evidence is increasingly being used for informing health policies. However, the underlining principles of health economic analyses are not always fully understood by non-health economists, and inappropriate types of analyses, as well as inconsistent methodologies, may be being used for informing health policy decisions. In addition, there is a lack of open access information and methodological guidance targeted to public health professionals particularly those based in low- and middle-income country (LMIC) settings. The objective of this review is to provide a comprehensive and accessible introduction to economic evaluations for public health professionals with a focus on LMIC settings. We cover the main principles underlining the most common types of full economic evaluations used in healthcare decision making in the context of priority setting (namely cost-effectiveness/cost-utility analyses, cost-benefit analyses), and outline their key features, strengths and weaknesses. It is envisioned that this will help those conducting such analyses, as well as stakeholders that need to interpret their output, gain a greater understanding of these methods and help them select/distinguish between the different approaches. In particular, we highlight the need for greater awareness of the methods used to place a monetary value on the health benefits of interventions, and the potential for such estimates to be misinterpreted. Specifically, the economic benefits reported are typically an approximation, summarizing the health benefits experienced by a population monetarily in terms of individual preferences or potential productivity gains, rather than actual realisable or fiscal monetary benefits to payers or society.

Journal article

Turner H, Stolk WA, Solomon AW, King JD, Montresor A, Molyneux DH, Toor Jet al., 2021, Are current preventive chemotherapy strategies for controlling and eliminating neglected tropical diseases cost-effective?, BMJ Global Health, Vol: 6, ISSN: 2059-7908

Neglected tropical diseases (NTDs) remain a significant cause of morbidity and mortality in many low- and middle-income countries. Several NTDs, namely lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiases (STH) and trachoma, are predominantly controlled by preventive chemotherapy (or mass drug administration), following recommendations set by the World Health Organization (WHO). Over one billion people are now treated for NTDs with this strategy per year. However, further investment and increased domestic healthcare spending are urgently needed to continue these programmes. Consequently, it is vital that the cost-effectiveness of preventive chemotherapy is understood. We analyse the current estimates on the cost per disability-adjusted life year (DALY) of the preventive chemotherapy strategies predominantly used for these diseases and identify key evidence gaps that require further research. Overall, the reported estimates show that preventive chemotherapy is generally cost-effective, supporting WHO recommendations. More specifically, the estimates relating to community-wide preventive chemotherapy for lymphatic filariasis and onchocerciasis were particularly favourable when compared to other public health interventions. Cost-effectiveness estimates of school-based preventive chemotherapy for schistosomiasis and STH were also generally favourable but more variable. No estimates of cost per DALY averted relating to community-wide mass antibiotic treatment for trachoma were found, highlighting the need for further research. These findings are important for informing global health policy and support the need for continuing NTD control and elimination efforts.

Journal article

Flower B, McCabe L, Le Ngoc C, Le Manh H, Le Thanh P, Dang Trong T, Vo Thi T, Vu Thi Kim H, Nguyen Tat T, Phan Thi Hong D, Nguyen Thi Chau A, Dinh Thi T, Tran Thi Tuyet N, Tarning J, Kingsley C, Kestelyn E, Pett SL, Thwaites G, Nguyen Van VC, Smith D, Barnes E, Ansari A, Turner H, Rahman M, Walker AS, Day J, Cooke GSet al., 2021, High cure rates for HCV genotype 6 in advanced liver fibrosis with 12 weeks sofosbuvir and daclatasvir: the Vietnam SEARCH study, Open Forum Infectious Diseases, Vol: 8, ISSN: 2328-8957

BackgroundGenotype 6 is the most genetically diverse lineage of hepatitis C virus (HCV), and predominates in Vietnam. It can be treated with sofosbuvir with daclatasvir (SOF/DCV), the lowest costing treatment combination globally. In regional guidelines, longer treatment durations of SOF/DCV (24 weeks) are recommended for cirrhotic individuals, compared with other pangenotypic regimens (12 weeks), based on sparse data. Early on-treatment virological response may offer means of reducing length and cost of therapy in patients with liver fibrosis.MethodsIn this prospective trial in Vietnam, genotype 6-infected adults with advanced liver fibrosis or compensated cirrhosis were treated with SOF/DCV. Day 14 viral load was used to guide duration of therapy: participants with viral load <500 IU/ml at day 14 were treated with 12 weeks of SOF/DCV and those ≥500 IU/ml received 24 weeks. Primary endpoint was sustained virological response.FindingsOf 41 individuals with advanced fibrosis or compensated cirrhosis who commenced treatment, 51% had genotype 6a, 34% 6e. The remainder had 6h, 6k, 6l or 6o. 100% had viral load <500 IU/ml by day 14, meaning all received 12 weeks of SOF/DCV. 100% achieved SVR12 despite a high frequency of putative NS5A inhibitor resistance-associated substitutions (RAS) at baseline.Interpretation12 weeks of SOF/DCV achieves excellent cure rates in this population. This data supports the removal of costly genotyping in countries where genotype 3 prevalence in <5%, in keeping with WHO guidelines. NS5A-resistance associated mutations in isolation, do not affect efficacy of SOF/DCV therapy. Wider evaluation of response-guided therapy is warranted.

Journal article

Huong NHT, Toan ND, Quy DT, Khanh TH, Thinh LQ, Nhan LNT, Minh NNQ, Turner H, Thwaites L, Irani S, Hung NT, Tan LVet al., 2021, Study protocol: The clinical features, epidemiology, and causes of paediatric encephalitis in southern Vietnam, Wellcome Open Research, Vol: 6, Pages: 133-133

<ns3:p>Encephalitis is a major cause of morbidity and mortality worldwide. The clinical syndrome of encephalitis consists of altered mental status, seizures, neurologic signs, and is often accompanied by fever, headache, nausea, and vomiting. The encephalitis in children has been known that more common than in adult, with the incidence rate of infants was 3.9 times higher than that of people 20-44 years of age. The reported incidence of hospitalization attributed to paediatric encephalitis ranged from 3 to 13 admissions per 100,000 children per year with the overall mortality ranging from 0 to 7%. There are however more than 100 pathogens that can cause encephalitis and accurate diagnosis is challenging. Over 50% of patients with encephalitis are left undiagnosed despite extensive laboratory investigations. Furthermore, recent studies in high-income settings have suggested autoimmune encephalitis has now surpassed infectious aetiologies, mainly due to increased awareness and diagnostic capacity, which further challenges routine diagnosis and clinical management, especially in developing countries.</ns3:p><ns3:p> There are limited contemporary data on the causes of encephalitis in children in Vietnam. Improving our knowledge of the causative agents of encephalitis in this resource-constrained setting remains critical to informing case management, resource distribution and vaccination strategy. Therefore, we conduct a prospective observational study to characterise the clinical, microbiological, and epidemiological features of encephalitis in a major children’s hospital in southern Vietnam. Admission clinical samples will be collected alongside meta clinical data and from each study participants. A combination of classical assays (serology and PCR) and metagenomic next-generation sequencing will used to identify the causative agents. Undiagnosed patients with clinical presentations compatible with autoimmune encephalitis will then be tested for

Journal article

Huong NHT, Toan ND, Quy DT, Khanh TH, Thinh LQ, Nhan LNT, Minh NNQ, Turner H, Thwaites L, Irani S, Hung NT, Tan LVet al., 2021, Study protocol: The clinical features, epidemiology, and causes of paediatric encephalitis in southern Vietnam, Wellcome Open Research, Vol: 6, Pages: 133-133

<ns4:p>Encephalitis is a major cause of morbidity and mortality worldwide. The clinical syndrome of encephalitis consists of altered mental status, seizures, neurologic signs, and is often accompanied by fever, headache, nausea, and vomiting. The encephalitis in children has been known that more common than in adult, with the incidence rate of infants was 3.9 times higher than that of people 20-44 years of age. The reported incidence of hospitalization attributed to paediatric encephalitis ranged from 3 to 13 admissions per 100,000 children per year with the overall mortality ranging from 0 to 7%. There are however more than 100 pathogens that can cause encephalitis and accurate diagnosis is challenging. Over 50% of patients with encephalitis are left undiagnosed despite extensive laboratory investigations. Furthermore, recent studies in high-income settings have suggested autoimmune encephalitis has now surpassed infectious aetiologies, mainly due to increased awareness and diagnostic capacity, which further challenges routine diagnosis and clinical management, especially in developing countries.</ns4:p><ns4:p> There are limited contemporary data on the causes of encephalitis in children in Vietnam. Improving our knowledge of the causative agents of encephalitis in this resource-constrained setting remains critical to informing case management, resource distribution and vaccination strategy. Therefore, we conduct a prospective observational study to characterise the clinical, microbiological, and epidemiological features of encephalitis in a major children’s hospital in southern Vietnam. Admission clinical samples will be collected alongside meta clinical data and from each study participants. A combination of classical assays (serology and PCR) and metagenomic next-generation sequencing will used to identify the causative agents. Undiagnosed patients with clinical presentations compatible with autoimmune encephalitis will then be tested for

Journal article

Turner H, 2021, Health Economic Analyses of the Global Programme to Eliminate Lymphatic Filariasis, International Health, Vol: 13, Pages: S71-S74, ISSN: 1876-3405

The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was established by the WHO in 2000. It aims to eliminate lymphatic filariasis as a public health problem. This paper summarises the key estimates of the cost-effectiveness and economic benefits related to the mass drug administration (MDA) provided by the GPELF. Several studies have investigated the cost-effectiveness of this MDA, estimating the cost per disability-adjusted life year (DALY) averted. These cost-effectiveness estimates have consistently classed the intervention as cost-effective and as favourable compared with other public health interventions conducted in low- and middle-income countries. Studies have also found that the MDA used for lymphatic filariasis control generates significant economic benefits. Although these studies are positive, there are still important gaps that warrant further health economic research (particularly, the evaluation of alternative interventions, further evaluation of morbidity management strategies and evaluation of interventions for settings coendemic with Loa loa). To conclude, health economic studies for a programme as large as the GPELF are subject to uncertainty. That said, the GPELF has consistently been estimated to be cost-effective and to generate notable economic benefits by a number of independent studies.

Journal article

Hung TM, Shepard DS, Bettis AA, Nguyen HA, McBride A, Clapham HE, Turner HCet al., 2020, Productivity costs from a dengue episode in Asia: a systematic literature review, BMC Infectious Diseases, Vol: 20, Pages: 1-18, ISSN: 1471-2334

BackgroundDengue is a mosquito-borne viral infection which has been estimated to cause a global economic burden of US$8.9 billion per year. 40% of this estimate was due to what are known as productivity costs (the costs associated with productivity loss from both paid and unpaid work that results from illness, treatment or premature death). Although productivity costs account for a significant proportion of the estimated economic burden of dengue, the methods used to calculate them are often very variable within health economic studies. The aim of this review was to systematically examine the current estimates of the productivity costs associated with dengue episodes in Asia and to increase awareness surrounding how productivity costs are estimated.MethodWe searched PubMed and Web of Knowledge without date and language restrictions using terms related to dengue and cost and economics burden. The titles and abstracts of publications related to Asia were screened to identify relevant studies. The reported productivity losses and costs of non-fatal and fatal dengue episodes were then described and compared. Costs were adjusted for inflation to 2017 prices.ResultsWe reviewed 33 relevant articles, of which 20 studies reported the productivity losses, and 31 studies reported productivity costs. The productivity costs varied between US$6.7–1445.9 and US$3.8–1332 for hospitalized and outpatient non-fatal episodes, respectively. The productivity cost associated with fatal dengue episodes varied between US$12,035-1,453,237. A large degree of this variation was due to the range of different countries being investigated and their corresponding economic status. However, estimates for a given country still showed notable variation.ConclusionWe found that the estimated productivity costs associated with dengue episodes in Asia are notable. However, owing to the significant variation in methodology and approaches applied, the reported productivity costs of dengue episod

Journal article

Sansom L, Minh TPN, Hill I, Ha QNT, Trong TD, Vidaillac C, Quynh ND, Turner H, Nuil JIV, Phuong DNT, Kestelyn Eet al., 2020, Towards a fair and transparent research participant compensation and reimbursement framework in Viet Nam, International Health, Vol: 12, Pages: 533-540, ISSN: 1876-3405

Background:Providing compensation for participants in clinical research is well established and whilst international guidelines exist, defining a context specific and fair compensation for participants in low resource settings is challenging due to ethical concerns and the lack of practical, nationalcompensation and reimbursement frameworks.Methods:We reviewed OUCRU (Oxford University Clinical Research Unit) internal reimbursement documentation over a ten-year period and conducted a scoping literature review to expand our knowledge of compensation and reimbursement practices including ethical concerns. We developed a preliminary reimbursement framework that was presented to Community Advisory Boards (CAB) and clinical investigators to assess its applicability, fairness, and transparency.Results: The main topics discussed at the workshops centered on fairness and whether the reimbursements could be perceived as financial incentives. Other decisive factors in the decision making process were altruism and the loss of caregivers’ earnings. Investigators raised the issueof additional burdens, whereas the CAB members were focused on non-monetary elements such as the healthcare quality the patients would receive. All elements discussed were reviewed and where possible, incorporated into the final framework.Conclusion:Our new reimbursement framework provides a consistent, fair and transparent decision-making process and will be implemented across all future OUCRU clinical research in Viet Nam.

Journal article

Nguyen HA, Cooke GS, Day JN, Flower B, Phuong LT, Hung TM, Dung NT, Khoa DB, Hung LM, Kestelyn E, Thwaites GE, Chau NVV, Turner HCet al., 2020, The direct-medical costs associated with interferon-based treatment for Hepatitis C in Vietnam, Wellcome Open Research, Vol: 4, Pages: 129-129

<ns4:p><ns4:bold>Background:</ns4:bold> Injectable interferon-based therapies have been used to treat hepatitis C virus (HCV) infection since 1991. International guidelines have now moved away from interferon-based therapy towards direct-acting antiviral (DAA) tablet regimens, because of their superior efficacy, excellent side-effect profiles, and ease of administration. Initially DAA drugs were prohibitively expensive for most healthcare systems. Access is now improving through the procurement of low-cost, generic DAAs acquired through voluntary licenses. However, HCV treatment costs vary widely, and many countries are struggling with DAA treatment scale-up. This is not helped by the limited cost data and economic evaluations from low- and middle-income countries to support HCV policy decisions. We conducted a detailed analysis of the costs of treating chronic HCV infection with interferon-based therapy in Vietnam. Understanding these costs is important for performing necessary economic evaluations of novel treatment strategies.</ns4:p><ns4:p> <ns4:bold>Methods:</ns4:bold> We conducted an analysis of the direct medical costs of treating HCV infection with interferon alpha (IFN) and pegylated-interferon alpha (Peg-IFN), in combination with ribavirin, from the health sector perspective at the Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam, in 2017.</ns4:p><ns4:p> <ns4:bold>Results:</ns4:bold> The total cost of the IFN treatment regimen was estimated to range between US$1,120 and US$1,962. The total cost of the Peg-IFN treatment regimen was between US$2,156 and US$5,887. Drug expenses were the biggest contributor to the total treatment cost (54-89%) and were much higher for the Peg-IFN regimen.</ns4:p><ns4:p> <ns4:bold>Conclusions:</ns4:bold> We found that treating HCV with IFN or Peg-IFN resulted in significant direct medical costs. Of concern, we found that all patie

Journal article

Turner HC, French MD, Montresor A, King CH, Rollinson D, Toor Jet al., 2020, Economic evaluations of human schistosomiasis interventions: a systematic review and identification of associated research needs, Wellcome Open Research, Vol: 5, Pages: 1-28, ISSN: 2398-502X

Background: Schistosomiasis is one of the most prevalent neglected tropical diseases (NTDs) with an estimated 229 million people requiring preventive treatment worldwide. Recommendations for preventive chemotherapy strategies have been made by the World Health Organization (WHO) whereby the frequency of treatment is determined by the settings prevalence. Despite recent progress, many countries still need to scale up treatment and important questions remain regarding optimal control strategies. This paper presents a systematic review of the economic evaluations of human schistosomiasis interventions.Methods: A systematic review of the literature was conducted on 22nd August 2019 using the PubMed (MEDLINE) and ISI Web of Science electronic databases. The focus was economic evaluations of schistosomiasis interventions, such as cost-effectiveness and cost-benefit analyses. No date or language stipulations were applied to the searches.Results: We identified 53 relevant health economic analyses of schistosomiasis interventions. Most studies related to Schistosoma japonicum followed by S. haematobium. Several studies also included other NTDs. In Africa, most studies evaluated preventive chemotherapy, whereas in China they mostly evaluated programmes using a combination of interventions (such as chemotherapy, snail control and health education). There was wide variation in the methodology and epidemiological settings investigated. A range of effectiveness metrics were used by the different studies.Conclusions: Due to the variation across the identified studies, it was not possible to make definitive policy recommendations. Although, in general, the current WHO recommended preventive chemotherapy approach to control schistosomiasis was found to be cost-effective. This finding has important implications for policymakers, advocacy groups and potential funders. However, there are several important inconsistencies and research gaps (such as how the health benefits of interventio

Journal article

Toor J, Rollinson D, Turner HC, Gouvras A, King CH, Medley GF, Hollingsworth TD, Anderson RMet al., 2020, Achieving elimination as a public health problem for schistosoma mansoni and S. haematobium: when is community-wide treatment required?, Journal of Infectious Diseases, Vol: 221, Pages: S525-S530, ISSN: 0022-1899

The World Health Organization (WHO) has set elimination as a public health problem (EPHP) as a goal for schistosomiasis. As the WHO treatment guidelines for schistosomiasis are currently under revision, we investigate whether school-based or community-wide treatment strategies are required for achieving the EPHP goal. In low- to moderate-transmission settings with good school enrolment, we find that school-based treatment is sufficient for achieving EPHP. However, community-wide treatment is projected to be necessary in certain high-transmission settings as well as settings with low school enrolment. Hence, the optimal treatment strategy depends on setting-specific factors such as the species present, prevalence prior to treatment, and the age profile of infection.

Journal article

Mathew CG, Bettis AA, Chu BK, English M, Ottesen EA, Bradley MH, Turner HCet al., 2020, The health and economic burdens of lymphatic filariasis prior to mass drug administration programs, Clinical Infectious Diseases, Vol: 70, Pages: 2561-2567, ISSN: 1058-4838

BACKGROUND: The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was launched in 2000 with the goal of eliminating lymphatic filariasis (LF) as a public health problem by 2020. Despite considerable progress, the current prevalence is around 60% of the 2000 figure, with the deadline looming a year away. Consequently, there is a continued need for investment in both the mass drug administration (MDA) and morbidity management programs, and this paper aims to demonstrate that need by estimating the health and economic burdens of LF prior to MDA programs starting in GPELF areas. METHODS: A previously developed model was used to estimate the numbers of individuals infected and individuals with symptomatic disease, along with the attributable number of disability-adjusted life years (DALYs). The economic burden was calculated by quantifying the costs incurred by the health-care system in managing clinical cases, the patients' out-of-pocket costs, and their productivity costs. RESULTS: Prior to the MDA program, approximately 129 million people were infected with LF, of which 43 million had clinical disease, corresponding to a DALY burden of 5.25 million. The average annual economic burden per chronic case was US $115, the majority of which resulted from productivity costs. The total economic burden of LF was estimated at US $5.8 billion annually. CONCLUSIONS: These results demonstrate the magnitude of the LF burden and highlight the continued need to support the GPELF. Patients with clinical disease bore the majority of the economic burden, but will not benefit much from the current MDA program, which is aimed at reducing transmission. This assessment further highlights the need to scale up morbidity management programs.

Journal article

McCabe L, White IR, Nguyen VVC, Barnes E, Pett SL, Cooke GS, Walker ASet al., 2020, The design and statistical aspects of VIETNARMS: a strategic post-licensing trial of multiple oral direct-acting antiviral hepatitis C treatment strategies in Vietnam, Trials, Vol: 21, Pages: 1-12, ISSN: 1745-6215

BackgroundEliminating hepatitis C is hampered by the costs of direct-acting antiviral treatment and the need to treat hard-to-reach populations. Access could be widened by shortening or simplifying treatment, but limited research means it is unclear which approaches could achieve sufficiently high cure rates to be acceptable. We present the statistical aspects of a multi-arm trial designed to test multiple strategies simultaneously and a monitoring mechanism to detect and stop individual randomly assigned groups with unacceptably low cure rates quickly.MethodsThe VIETNARMS trial will factorially randomly assign patients to two drug regimens, three treatment-shortening strategies or control, and adjunctive ribavirin or no adjunctive ribavirin with shortening strategies (14 randomly assigned groups). We will use Bayesian monitoring at interim analyses to detect and stop recruitment into unsuccessful strategies, defined by more than 0.95 posterior probability that the true cure rate is less than 90% for the individual randomly assigned group (non-comparative). Final comparisons will be non-inferiority for regimens (margin 5%) and strategies (margin 10%) and superiority for adjunctive ribavirin. Here, we tested the operating characteristics of the stopping guideline for individual randomly assigned groups, planned interim analysis timings and explored power at the final analysis.ResultsA beta (4.5, 0.5) prior for the true cure rate produces less than 0.05 probability of incorrectly stopping an individual randomly assigned group with a true cure rate of more than 90%. Groups with very low cure rates (<60%) are very likely (>0.9 probability) to stop after about 25% of patients are recruited. Groups with moderately low cure rates (80%) are likely to stop (0.7 probability) before overall recruitment finishes. Interim analyses 7, 10, 13 and 18 months after recruitment commences provide good probabilities of stopping inferior individua

Journal article

Turner HC, Bundy DAP, 2020, Programmatic implications of the TUMIKIA trial on community-wide treatment for soil-transmitted helminths: further health economic analyses needed before a change in policy, Parasites and Vectors, Vol: 13, ISSN: 1756-3305

School-based deworming programmes are currently the main approach used to control the soil-transmitted helminths (STHs). A key unanswered policy question is whether mass drug administration (MDA) should be targeted tothe whole community instead, and several trials in this area have been conducted or are currently on-going. A recentwell-conducted trial demonstrated that successful community-wide treatment is a feasible strategy for STH controland can be more efective than school-based treatment in reducing prevalence and intensity of hookworm infection. However, we would argue that it is vital that these fndings are not taken out of context or over generalised, asthe additional health benefts gained from switching to community-wide treatment will vary depending on the STHspecies and baseline endemicity. Moreover, community-wide treatment will typically be more expensive than schoolbased treatment. The epidemiological evidence for an additional beneft from a switch to community-wide treatmenthas yet to be proven to represent “good value for money” across diferent settings. Further work is needed beforechanges in policy are made regarding the use of community-wide treatment for STH control, including comprehensive assessments of its additional public health benefts and costs across a range of scenarios, accounting for thepresence of alternative treatment delivery platforms.

Journal article

Deribe K, Negussu N, Newport MJ, Davey G, Turner HCet al., 2020, The health and economic burden of podoconiosis in Ethiopia, Transactions of The Royal Society of Tropical Medicine and Hygiene, Vol: 114, Pages: 284-292, ISSN: 0035-9203

BackgroundPodoconiosis is one of the leading causes of lymphoedema-related morbidity in low-income settings, but little is known about the scale of its health and economic impact. This information is required to inform control programme planning and policy. In this study, we estimated the health and economic burden of podoconiosis in Ethiopia.MethodsWe developed a model to estimate the health burden attributed to podoconiosis in terms of the number of disability-adjusted life years (DALYs) and the economic burden. We estimated the economic burden by quantifying the treatment and morbidity-management costs incurred by the healthcare system in managing clinical cases, patients' out-of-pocket costs and their productivity costs.ResultsIn 2017, there were 1.5 million cases of podoconiosis in Ethiopia, which corresponds to 172 073 DALYs or 182 per 100 000 people. The total economic burden of podoconiosis in Ethiopia is estimated to be US$213.2 million annually and 91.1% of this resulted from productivity costs. The average economic burden per podoconiosis case was US$136.9.ConclusionsThe national cost of podoconiosis is formidable. If control measures are scaled up and the morbidity burden reduced, this will lead to Ethiopia saving millions of dollars. Our estimates provide important benchmark economic costs to programme planners, policymakers and donors for resource allocation and priority setting.

Journal article

Tran BX, Nguyen LH, Turner HC, Nghiem S, Vu GT, Nguyen CT, Latkin CA, Ho CSH, Ho RCMet al., 2019, Economic evaluation studies in the field of HIV/AIDS: bibliometric analysis on research development and scopes (GAPRESEARCH), BMC Health Services Research, Vol: 19, ISSN: 1472-6963

BACKGROUND: The rapid decrease in international funding for HIV/AIDS has been challenging for many nations to effectively mobilize and allocate their limited resources for HIV/AIDS programs. Economic evaluations can help inform decisions and strategic planning. This study aims to examine the trends and patterns in economic evaluation studies in the field of HIV/AIDS and determine their research landscapes. METHODS: Using the Web of Science databases, we synthesized the number of papers and citations on HIV/AIDS and economic evaluation from 1990 to 2017. Collaborations between authors and countries, networks of keywords and research topics were visualized using frequency of co-occurrence and Jaccards' similarity index. A Latent Dirichlet Allocation (LDA) analysis to categorize papers into different topics/themes. RESULTS: A total of 372 economic evaluation papers were selected, including 351 cost-effectiveness analyses (CEA), 11 cost-utility analyses (CUA), 12 cost-benefit analyses (CBA). The growth of publications, their citations and usages have increased remarkably over the years. Major research topics in economic evaluation studies consisted of antiretroviral therapy (ART) initiation and treatment; drug use prevention interventions and prevention of mother-to-child transmission interventions. Moreover, lack of contextualized evidence was found in specific settings with high burden HIV epidemics, as well as emerging most-at-risk populations such as trans-genders or migrants. CONCLUSION: This study highlights the knowledge and geographical discrepancies in HIV/AIDS economic evaluation literature. Future research directions are also informed for advancing economic evaluation in HIV/AIDS research.

Journal article

Collyer BS, Turner HC, Hollingsworth TD, Keeling MJet al., 2019, Vaccination or mass drug administration against schistosomiasis: a hypothetical cost-effectiveness modelling comparison, Parasites and Vectors, Vol: 12, Pages: 1-14, ISSN: 1756-3305

BackgroundSchistosomiasis is a neglected tropical disease, targeted by the World Health Organization for reduction in morbidity by 2020. It is caused by parasitic flukes that spread through contamination of local water sources. Traditional control focuses on mass drug administration, which kills the majority of adult worms, targeted at school-aged children. However, these drugs do not confer long-term protection and there are concerns over the emergence of drug resistance. The development of a vaccine against schistosomiasis opens the potential for control methods that could generate long-lasting population-level immunity if they are cost-effective.MethodsUsing an individual-based transmission model, matched to epidemiological data, we compared the cost-effectiveness of a range of vaccination programmes against mass drug administration, across three transmission settings. Health benefit was measured by calculating the heavy-intensity infection years averted by each intervention, while vaccine costs were assessed against robust estimates for the costs of mass drug administration obtained from data. We also calculated a critical vaccination cost, a cost beyond which vaccination might not be economically favorable, by benchmarking the cost-effectiveness of potential vaccines against the cost-effectiveness of mass drug administration, and examined the effect of different vaccine protection durations.ResultsWe found that sufficiently low-priced vaccines can be more cost-effective than traditional drugs in high prevalence settings, and can lead to a greater reduction in morbidity over shorter time-scales. MDA or vaccination programmes that target the whole community generate the most health benefits, but are generally less cost-effective than those targeting children, due to lower prevalence of schistosomiasis in adults.ConclusionsThe ultimate cost-effectiveness of vaccination will be highly dependent on multiple vaccine characteristics, such as the efficacy, cost, safety

Journal article

McBride A, Thuy Duong B, Chau Nguyen VV, Thwaites CL, Turner HC, Hao Nguyen Vet al., 2019, Catastrophic health care expenditure due to septic shock and dengue shock in Vietnam, Transactions of the Royal Society of Tropical Medicine and Hygiene, Vol: 113, Pages: 649-651, ISSN: 0035-9203

BACKGROUND: The cost of treatment for infectious shock in intensive care in Vietnam is unknown. METHODS: We prospectively investigated hospital bills for adults treated for septic and dengue shock in Vietnam and calculated the proportion who faced catastrophic health care expenditures. RESULTS: The median hospital bills were US$617 for septic shock (n=100) and US$57 for dengue shock (n=88). Catastrophic payments were incurred by 47% (47/100) and 13% (11/88) of patients with septic shock and dengue shock, respectively, and 56% (25/45) and 84% (5/6) fatal cases of septic shock and dengue shock respectively. CONCLUSIONS: Further advocacy is required to moderate insurance co-payments for costly critical care interventions.

Journal article

Toor J, Truscott JE, Werkman M, Turner HC, Phillips AE, King CH, Medley GF, Anderson RMet al., 2019, Determining post-treatment surveillance criteria for predicting the elimination of Schistosoma mansoni transmission, Parasites and Vectors, Vol: 12, ISSN: 1756-3305

BACKGROUND: The World Health Organization (WHO) has set elimination (interruption of transmission) as an end goal for schistosomiasis. However, there is currently little guidance on the monitoring and evaluation strategy required once very low prevalence levels have been reached to determine whether elimination or resurgence of the disease will occur after stopping mass drug administration (MDA) treatment. METHODS: We employ a stochastic individual-based model of Schistosoma mansoni transmission and MDA impact to determine a prevalence threshold, i.e. prevalence of infection, which can be used to determine whether elimination or resurgence will occur after stopping treatment with a given probability. Simulations are run for treatment programmes with varying probabilities of achieving elimination and for settings where adults harbour low to high burdens of infection. Prevalence is measured based on using a single Kato-Katz on two samples per individual. We calculate positive predictive values (PPV) using PPV ≥ 0.9 as a reliable measure corresponding to ≥ 90% certainty of elimination. We analyse when post-treatment surveillance should be carried out to predict elimination. We also determine the number of individuals across a single community (of 500-1000 individuals) that should be sampled to predict elimination. RESULTS: We find that a prevalence threshold of 1% by single Kato-Katz on two samples per individual is optimal for predicting elimination at two years (or later) after the last round of MDA using a sample size of 200 individuals across the entire community (from all ages). This holds regardless of whether the adults have a low or high burden of infection relative to school-aged children. CONCLUSIONS: Using a prevalence threshold of 0.5% is sufficient for surveillance six months after the last round of MDA. However, as such a low prevalence can be difficult to measure in the field using Kato-Katz, we recommend using 1% two ye

Journal article

Nguyen HA, Cooke GS, Day JN, Flower B, Phuong LT, Hung TM, Dung NT, Khoa DB, Hung LM, Kestelyn E, Thwaites GE, Chau NVV, SEARCH Investigators, Turner HCet al., 2019, The direct-medical costs associated with interferon-based treatment for Hepatitis C in Vietnam., Wellcome Open Res, Vol: 4, Pages: 1-15, ISSN: 2398-502X

Background: Injectable interferon-based therapies have been used to treat hepatitis C virus (HCV) infection since 1991. International guidelines have now moved away from interferon-based therapy towards direct-acting antiviral (DAA) tablet regimens, because of their superior efficacy, excellent side-effect profiles, and ease of administration. Initially DAA drugs were prohibitively expensive for most healthcare systems. Access is now improving through the procurement of low-cost, generic DAAs acquired through voluntary licenses. However, HCV treatment costs vary widely, and many countries are struggling with DAA treatment scale-up. This is not helped by the limited cost data and economic evaluations from low- and middle-income countries to support HCV policy decisions. We conducted a detailed analysis of the costs of treating chronic HCV infection with interferon-based therapy in Vietnam. Understanding these costs is important for performing necessary economic evaluations of novel treatment strategies. Methods: We conducted an analysis of the direct medical costs of treating HCV infection with interferon alpha (IFN) and pegylated-interferon alpha (Peg-IFN), in combination with ribavirin, from the health sector perspective at the Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam, in 2017. Results: The total cost of the IFN treatment regimen was estimated to range between US$1,120 and US$1,962. The total cost of the Peg-IFN treatment regimen was between US$2,156 and US$5,887. Drug expenses were the biggest contributor to the total treatment cost (54-89%) and were much higher for the Peg-IFN regimen. Conclusions: We found that treating HCV with IFN or Peg-IFN resulted in significant direct medical costs. Of concern, we found that all patients incurred substantial out-of-pocket costs, including those receiving the maximum level of support from the national health insurance programme. This cost data highlights the potential savings and importance of increased acc

Journal article

Hung TM, Wills B, Clapham HE, Yacoub S, Turner HCet al., 2019, The uncertainty surrounding the burden of post-acute consequences of dengue infection, Trends in Parasitology, Vol: 35, Pages: 673-676, ISSN: 0169-4758

Post-acute consequences currently form a significant component of the dengue disability-adjusted life year (DALY) burden estimates. However, there is considerable uncertainty regarding the incidence, duration, and severity of these symptoms. Further research is needed to more accurately estimate the health and economic burden of these dengue manifestations.

Journal article

Turner HC, Lauer JA, Tran BX, Teerawattananon Y, Jit Met al., 2019, Adjusting for inflation and currency changes within health economic studies, Value in Health, Vol: 22, Pages: 1026-1032, ISSN: 1098-3015

OBJECTIVES: Within health economic studies, it is often necessary to adjust costs obtained from different time periods for inflation. Nevertheless, many studies do not report the methods used for this in sufficient detail. In this article, we outline the principal methods used to adjust for inflation, with a focus on studies relating to healthcare interventions in low- and middle-income countries. We also discuss issues relating to converting local currencies to international dollars and US$ and adjusting cost data collected from other countries or previous studies. METHODS: We outlined the 3 main methods used to adjust for inflation for studies in these settings: exchanging the local currency to US$ or international dollars and then inflating using US inflation rates (method 1); inflating the local currency using local inflation rates and then exchanging to US$ or international dollars (method 2); splitting the costs into tradable and nontradable resources and using method 1 on the tradable resources and method 2 on the nontradable resources (method 3). RESULTS: In a hypothetical example of adjusting a cost of US$100 incurred in Vietnam from 2006 to 2016 prices, the adjusted cost from the 3 methods were US$116.84, US$172.09, and US$161.04, respectively. CONCLUSIONS: The different methods for adjusting for inflation can yield substantially different results. We make recommendations regarding the most appropriate method for various scenarios. Moving forward, it is vital that studies report the methodology they use to adjust for inflation more transparently.

Journal article

Carrique-Mas J, Van Cuong N, Truong BD, Phu DH, Phuc TM, Turner H, Thwaites G, Baker Set al., 2019, Affordability of antimicrobials for animals and humans in Vietnam: A call to revise pricing policies, International Journal of Antimicrobial Agents, Vol: 54, Pages: 269-270, ISSN: 0924-8579

Journal article

Turner HC, Walker M, Pion SDS, McFarland DA, Bundy DAP, Basanez M-Get al., 2019, Economic evaluations of onchocerciasis interventions: a systematic review and research needs, Tropical Medicine and International Health, Vol: 24, Pages: 788-816, ISSN: 1360-2276

ObjectiveTo provide a systematic review of economic evaluations that has been conducted for onchocerciasis interventions, to summarise current key knowledge and to identify research gaps.MethodA systematic review of the literature was conducted on the 8th of August 2018 using the PubMed (MEDLINE) and ISI Web of Science electronic databases. No date or language stipulations were applied to the searches.ResultsWe identified 14 primary studies reporting the results of economic evaluations of onchocerciasis interventions, seven of which were cost‐effectiveness analyses. The studies identified used a variety of different approaches to estimate the costs of the investigated interventions/programmes. Originally, the studies only quantified the benefits associated with preventing blindness. Gradually, methods improved and also captured onchocerciasis‐associated skin disease. Studies found that eliminating onchocerciasis would generate billions in economic benefits. The majority of the cost‐effectiveness analyses evaluated annual mass drug administration (MDA). The estimated cost per disability‐adjusted life year (DALY) averted of annual MDA varies between US$3 and US$30 (cost year variable).ConclusionsThe cost benefit and cost effectiveness of onchocerciasis interventions have consistently been found to be very favourable. This finding provides strong evidential support for the ongoing efforts to eliminate onchocerciasis from endemic areas. Although these results are very promising, there are several important research gaps that need to be addressed as we move towards the 2020 milestones and beyond.

Journal article

Nhan LNT, Turner HC, Khanh TH, Hung NT, Lien LB, Hong NTT, Nhu LNT, Ny NTH, Nguyet LA, Thanh TT, Van HMT, Viet HL, Tung TH, Phuong TTL, Devine A, Thwaites G, Chau NVV, Thwaites L, van Doorn HR, Tan LVet al., 2019, Economic burden attributed to children presenting to hospitals with hand, foot, and mouth disease in Vietnam, Open Forum Infectious Diseases, Vol: 6, ISSN: 2328-8957

BACKGROUND: Hand, foot, and mouth disease (HFMD) has become a major public health concern in the Asia-Pacific region. Knowledge of its economic burden is essential for policy makers in prioritizing the development and implementation of interventions. METHODS: A multi-hospital-based study was prospectively conducted at 3 major hospitals in Ho Chi Minh City, Vietnam, during 2016-2017. Data on direct and productivity costs were collected alongside clinical information and samples and demographic information from study participants. RESULTS: A total of 466 patients were enrolled. Two hundred three of 466 (43.6%) patients lived in Ho Chi Minh City, and 72/466 (15.5%) had severe HFMD. An enterovirus was identified in 74% of 466 patients, with EV-A71, CV-A6, CV-A10, and CV-A16 being the most common viruses identified (236/466, 50.6%). The mean economic burden per case was estimated at US$400.80 (95% confidence interval [CI], $353.80-$448.90), of which the total direct (medical) costs accounted for 69.7%. There were considerable differences in direct medical costs between groups of patients with different clinical severities and pathogens (ie, EV-A71 vs non-EV-A71). In Vietnam, during 2016-2017, the economic burden posed by HFMD was US$90 761 749 (95% CI, $79 033 973-$103 009 756). CONCLUSIONS: Our findings are of public health significance because for the first time we demonstrate that HFMD causes a substantial economic burden in Vietnam, and although multivalent vaccines are required to control HFMD, effective EV-A71 vaccine could substantially reduce the burden posed by severe HFMD. The results will be helpful for health policy makers in prioritizing resources for the development and implementation of intervention strategies to reduce the burden of HFMD.

Journal article

Turner HC, Nguyen VH, Yacoub S, Van MTH, Clifton DA, Thwaites GE, Dondorp AM, Thwaites CL, Nguyen VVCet al., 2019, Achieving affordable critical care in low-income and middle-income countries, BMJ Global Health, Vol: 4, Pages: 1-4, ISSN: 2059-7908

Journal article

Huong VTL, Turner HC, Kinh NV, Thai PQ, Hoa NT, Horby P, van Doorn HR, Wertheim HFLet al., 2019, Burden of disease and economic impact of human Streptococcus suis infection in Viet Nam, Transactions of the Royal Society of Tropical Medicine and Hygiene, Vol: 113, Pages: 341-350, ISSN: 0035-9203

BACKGROUND: Streptococcus suis is a zoonotic disease mainly affecting men of working age and can result in death or long-term sequelae, including severe hearing loss and vestibular dysfunction. We aimed to quantify the burden of disease and economic impact of this infection in Viet Nam. METHODS: The annual disease incidence for the period 2011-2014 was estimated based on surveillance data using a multiple imputation approach. We calculated disease burden in disability-adjusted life years (DALYs) and economic costs using an incidence-based approach from a patient's perspective and including direct and indirect impacts of S. suis infection and its long-term sequelae. RESULTS: The estimated annual incidence rate was 0.318, 0.324, 0.255 and 0.249 cases per 100 000 population in 2011, 2012, 2013 and 2014, respectively. The corresponding DALYs lost were 1832, 1866, 1467 and 1437. The mean direct cost per episode was US$1635 (95% confidence interval 1352-1923). The annual direct cost was US$370 000-500 000 and the indirect cost was US$2.27-2.88 million in this time period. CONCLUSIONS: This study showed a large disease burden and high economic impact of S. suis infection and provides important data for disease monitoring and control.

Journal article

Turner HC, Toor J, Bettis AA, Hopkins AD, Kyaw SS, Onwujekwe O, Thwaites GE, Lubell Y, Fitzpatrick Cet al., 2019, Valuing the unpaid contribution of community health volunteers to mass drug administration programs, Clinical Infectious Diseases, Vol: 68, Pages: 1588-1595, ISSN: 1058-4838

Community health volunteers (CHVs) are being used within a growing number of healthcare interventions, and they have become a cornerstone for the delivery of mass drug administration within many neglected tropical disease control programs. However, a greater understanding of the methods used to value the unpaid time CHVs contribute to healthcare programs is needed. We outline the two main approaches used to value CHVs' unpaid time (the opportunity cost and the replacement cost approaches). We found that for mass drug administration programs the estimates of the economic costs relating to the CHVs' unpaid time can be significant, with the averages of the different studies varying between US$0.05-0.16 per treatment. We estimated that the time donated by CHVs' to the African Programme for Onchocerciasis Control alone would be valued between US$60-90 million. There is a need for greater transparency and consistency in the methods used to value CHVs' unpaid time.

Journal article

Loan HT, Yen LM, Kestelyn E, Hao NV, Thanh TT, Dung NTP, Turner HC, Geskus RB, Wolbers M, Tan LV, Van Doorn HR, Day NP, Wyncoll D, Hien TT, Thwaites GE, Vinh Chau NV, Thwaites CLet al., 2018, Intrathecal Immunoglobulin for treatment of adult patients with tetanus: A randomized controlled 2x2 factorial trial, Wellcome Open Research, Vol: 3, ISSN: 2398-502X

Despite long-standing availability of an effective vaccine, tetanus remains a significant problem in many countries. Outcome depends on access to mechanical ventilation and intensive care facilities and in settings where these are limited, mortality remains high. Administration of tetanus antitoxin by the intramuscular route is recommended treatment for tetanus, but as the tetanus toxin acts within the central nervous system, it has been suggested that intrathecal administration of antitoxin may be beneficial. Previous studies have indicated benefit, but with the exception of one small trial no blinded studies have been performed. The objective of this study is to establish whether the addition of intrathecal tetanus antitoxin reduces the need for mechanical ventilation in patients with tetanus. Secondary objectives: to determine whether the addition of intrathecal tetanus antitoxin reduces autonomic nervous system dysfunction and length of hospital/ intensive care unit stay; whether the addition of intrathecal tetanus antitoxin in the treatment of tetanus is safe and cost-effective; to provide data to inform recommendation of human rather than equine antitoxin. This study will enroll adult patients (≥16 years old) with tetanus admitted to the Hospital for Tropical Diseases, Ho Chi Minh City. The study is a 2x2 factorial blinded randomized controlled trial. Eligible patients will be randomized in a 1:1:1:1 manner to the four treatment arms (intrathecal treatment and human intramuscular treatment, intrathecal treatment and equine intramuscular treatment, sham procedure and human intramuscular treatment, sham procedure and equine intramuscular treatment). Primary outcome measure will be requirement for mechanical ventilation. Secondary outcome measures: duration of hospital/ intensive care unit stay, duration of mechanical ventilation, in-hospital and 240-day mortality and disability, new antibiotic prescription, incidence of ventilator associated pneumonia and aut

Journal article

Dat VQ, Huong VTL, Turner HC, Thwaites L, van Doorn HR, Nadjm Bet al., 2018, Excess direct hospital cost of treating adult patients with ventilator associated respiratory infection (VARI) in Vietnam, PLoS One, Vol: 13, ISSN: 1932-6203

INTRODUCTION: Ventilator associated respiratory infections (VARIs) are the most common hospital acquired infections in critical care worldwide. This work aims to estimate the total annual direct hospital cost of treating VARI throughout Vietnam. METHODS: A costing model was constructed to evaluate the excess cost of diagnostics and treatment of VARI in Vietnam. Model inputs included costs for extra lengths of stay, diagnostics, VARI incidence, utilisation of ventilators and antibiotic therapy. RESULTS: With the current VARI incidence rate of 21.7 episodes per 1000 ventilation-days, we estimated 34,428 VARI episodes in the 577 critical care units in Vietnam per year. The extra cost per VARI episode was $1,174.90 and the total annual excess cost was US$40.4 million. A 1% absolute reduction in VARI incidence density would save US$1.86 million annually. For each episode of VARI, the share of excess cost components was 45.1% for critical care unit stay and ventilation, 3.7% for diagnostics and 51.1% for extra antimicrobial treatment. CONCLUSIONS: At the current annual government health expenditure of US$117 per capita, VARI represents a substantial cost to the health service in Vietnam. Enhanced infection prevention and control and antimicrobial stewardship programmes should be implemented to reduce this.

Journal article

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