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Economic Evaluation of 2012
Fungal Meningitis Outbreak
in New River Valley
Nargesalsadat Dorratoltaj, MS, MPH
Department of Population Health Sciences, Virginia Tech, Blacksburg, VA
Margaret O'Dell, MD, MFA
New River Health District, Virginia Department of Health, Christiansburg, VA
Page Bordwine, MPH, MT(ASCP)
New River Health District, Christiansburg, VA
Thomas Kerkering, MD, FACP, FIDSA
Carilion Clinic, Virginia Tech Carilion School of Medicine, Roanoke, VA
Kerry Redican, PhD, MPH, MSPH, CHES
Department of Population Health Sciences, Virginia Tech, Blacksburg, VA
Kaja Abbas, PhD, MPH
Department of Population Health Sciences, Virginia Tech, Blacksburg, VA
Conflict of Interest: None
• We declare that we have no conflict of
interest, and we comply with the American
Public Health Association Conflict of Interest
and Commercial Support Guidelines.
Learning objectives
• Identify the costs and effectiveness of 2012 fungal meningitis
outbreak response in New River Valley, Virginia.
• Evaluate the incremental cost-effectiveness ratio of the fungal
meningitis outbreak response.
• Assess the incremental cost-effectiveness ratio to prioritize the
limited resources of the local health department.
Study Objective
The objective of this study is :
To conduct an economic evaluation of fungal
meningitis outbreak response from local health
department and clinical facilities perspectives.
Background
• What is fungal meningitis?
• Nationwide outbreak
• Outbreak in Virginia
What is fungal meningitis?
• Fungus spread through blood to the spinal cord
• Swelling of protective membranes, covering brain, and spinal cord
• Not contagious
• Signs and symptoms:
• Fever
• Headache
• Stiff neck
• Nausea and vomiting
• Photophobia (sensitivity to light)
• Altered mental status
• Treatment is with long courses of high dose antifungal medications
• Voriconazole
Pathogenesis
• Predominant Pathogen:
Exserohilum rostratum (a brown-black mold)
• Index case Infection:
Aspergillus fumigatus
• Common in the Environment
• Risk factors:
• Immunocompromised patients
• Loss of immunity associated with age
Nationwide outbreak
• Started in September 2012 at Tennessee
• Methylprednisolone Acetate (MPA) used for
Epidural Spinal Injections (ESI)
• Contaminated MPA lots were produced in a
Compounding pharmacy in MA.
Contaminated injections put 13,000 people at risk of fungal meningitis.
Final count: 751 cases , 64 deaths, 20 states
• States received contaminated MPA lots:
• States with confirmed cases:
Source: CDC
Contaminated lots in Virginia
• Two facilities in Virginia received the contaminated lots:
• Insight Imaging, Roanoke Valley
• New River Valley Surgery Center, Christiansburg VA
• Local Health Departments started their surveillance in October
2012 to control the outbreak.
Public Health Significance
Public Health Significance
• Virginia with 54 cases and 5 deaths affected significantly by the
outbreak.
• Cost effectiveness analysis assists the local health department to
prioritize its resources effectively and efficiently.
Methods
• New River Health District surveillance system
• Incremental Cost Effectiveness Ratio (ICER)
New River Health District surveillance system
Incremental Cost Effectiveness Ratio (ICER)
• Used in economic evaluation of health programs
• Useful approach for making decisions about new interventions
• Ratio of the change in the costs to incremental benefit of an
intervention
Costs
• Cost of new intervention
o Local health department cost
• New River Health District
o Local clinical facilities cost
• Lewis Gale
o Montgomery
o Salem
o Pulaski
• Roanoke Carillion
• Cost of control
o No intervention from local
health department.
Effectiveness: Disability Adjusted Life Years(DALY) averted
Results
•
•
•
•
Local health department cost
Clinical facility cost
Effectiveness
Incremental Cost-Effectiveness Cost (ICER)
Local health department costs
NRHD Division
Total Cost
Epidemiologists
Director of Health District
$16,748.5
$6,746.9
Planner
EH Manager
Clerical
Admin
Nurse Epi
Volunteers
Total
$1,558.7
$511.0
$372.8
$240.0
$575.5
$3,739.5
$30,492.9
Clinical facilities costs
New River Valley had more than 90 exposed patients
• 14 patients: CSF cultured
• 12 patients: Lumbar Puncture Test
• 9 patients: Have admission records at local clinical facilities
Total Cost: $41,667
Effectiveness
Parameter
DALY
Estimation
2.87+97.65=100.52
YLL(With treatment)
# of potential cases
Case fatality
Average life expectancy in Virginia
Average age of exposed patients
10.15 years
7
10%
79 years
57 years
YLL (Without treatment)
# of potential cases
Case fatality
Average life expectancy in Virginia
Average age of exposed patients
107.8 years
7
70%
79 years
57 years
YLD(With treatment)
Disability weight
|10.15-107.8|=
97.65
2.87 years
0.615, [0.613,0.616]
8 months
[3 months- 1yr]
YLL
Average duration of Disease
YLD(Without treatment)
YLD
0
2.87
Incremental Cost Effectiveness Ratio
=
𝐿𝑜𝑐𝑎𝑙 ℎ𝑒𝑎𝑙𝑡ℎ 𝐷𝑒𝑝𝑎𝑟𝑡𝑚𝑒𝑛𝑡 𝑐𝑜𝑠𝑡+𝐶𝑙𝑖𝑛𝑖𝑐𝑎𝑙 𝑓𝑎𝑐𝑖𝑙𝑖𝑡𝑦 𝑐𝑜𝑠𝑡 −0
(𝑌𝐿𝐿+𝑌𝐿𝐷)𝑂𝑢𝑡𝑏𝑟𝑒𝑎𝑘 𝑟𝑒𝑠𝑝𝑜𝑛𝑠𝑒 − (𝑌𝐿𝐿+𝑌𝐿𝐷)𝑁𝑜 𝑟𝑒𝑠𝑝𝑜𝑛𝑠𝑒
$ 30,492+41,667 −0
=
97.56 +(2.87)
= $717.86 per DALY averted
Discussion
Discussion
• The cost effectiveness ratio of this outbreak
response from the local health department
and clinical facilities perspective, is $718
per DALY averted.
Cost effectiveness thresholds
Public Health Implications
Public Health Implications
The results of this study can help decision makers at
local health departments to prioritize among different
outbreak responses in resource limited areas.
Limitations
Limitations
• No confirmed case of fungal meningitis
• Estimation of clinical facility cost
• Cost of control for clinical facilities
• Estimation of fungal meningitis characteristics
Future Work
Future work
• Add state and federal level to the ICER
calculation.
• Apply the ICER calculation in health
district with confirmed cases
Multi-layered response to the fungal meningitis outbreak
Acknowledgements
Public Health Program
References
[1] Kainer, M. A., Reagan, D. R., Nguyen, D. B., Wiese, A. D., Wise, M. E., Ward, J., & Jones, T. F. (2012). Fungal infections associated with contaminated
methylprednisolone in Tennessee. New England Journal of Medicine, 367(23), 2194-2203.
2] Centers for Disease Control and Prevention. Multistate outbreak of fungal infection associated with injection of methylprednisolone acetate solution from a
single compounding pharmacy - united states, 2012. MMWR. Morbidity and mortality weekly report, 61(41):839{8 42, October 2012. PMID: 23076093.
[3] Center for Disease Control and Prevention. Multistate fungal meningitis outbreak investigation. http://www.cdc.gov/HAI/outbreaks/meningitis.html.
[Accessed 15 August 2013]
[4] Smith, R. M., Schaefer, M. K., Kainer, M. A., Wise, M., Finks, J., Duwve, J., & Park, B. J. (19). December 2012. Fungal infections associated with contaminated
methylprednisolone injections—preliminary report. N. Engl. J. Med.[Epub ahead of print.] doi, 10.
[5] Kauffman, C. A., Pappas, P. G., & Patterson, T. F. (2013). Fungal infections associated with contaminated methylprednisolone injections. New England Journal of
Medicine, 368(26), 2495-2500.
[6] Measure of America, 2013-2014.
[7] Rosenstein, N. E., Perkins, B. A., Stephens, D. S., Popovic, T., & Hughes, J. M. (2001). Meningococcal disease. New England Journal of Medicine, 344(18), 1378-1388.
[8] Meningitis Causes, Mayo Clinic. http://www.mayoclinic.org/diseases-conditions/meningitis/basics/causes/con-20019713, accessed on March 31, 2014
[9] Mathers, C., Fat, D. M., & Boerma, J. T. (2008). The global burden of disease: 2004 update. World Health Organization.
[10] Centers for Disease Control and Prevention (CDC). (2012). Multistate fungal meningitis outbreak investigation interim treatment guidance for central nervous
system and/or parameningeal infections associated with injection of potentially contaminated steroid products
[11] Case Definitions for Fungal Meningitis and Other Infections. (2013, October 23). Centers for Disease Control and Prevention. Retrieved April 16, 2014, from
http://www.cdc.gov/hai/outbreaks/clinicians/index.html
[12] Grosse, S. D. (2008). Assessing cost-effectiveness in healthcare: history of the $50,000 per QALY threshold.
[13] Lumbar Puncture, Healthcare Bluebook, from https://www.healthcarebluebook.com/page_Results.aspx?id=375&dataset=MD
[14] Barenfanger, J., Lawhorn, J., & Drake, C. (2004). Nonvalue of culturing cerebrospinal fluid for fungi. Journal of clinical microbiology, 42(1), 236-238.
[15] Caldwell, N., Srebotnjak, T., Wang, T., & Hsia, R. (2013). “How Much Will I Get Charged for This?” Patient Charges for Top Ten Diagnoses in the Emergency
Department. PloS one, 8(2), e55491.
Thank you!
Contact: Narges Dorratoltaj
[email protected]
Benefits
• DALY = Years of Life Lost (YLL) + Years of Life Lost due to Disability (YLD)
• YLL=
• YLD =
Number of potential cases x case fatality
x
(Average life expectancy- Average Age at time of death)
Number of cases
x
Disability Weight
x
Average duration of the disease until remission or death