The health and economic burden of rotavirus disease in Belgium

For health economic evaluations of rotavirus vaccination, estimates of the health and cost burden of rotavirus are required. Due to differences in health care systems and surveillance organisations, this is difficult to achieve by imputing estimates from one country to others. This study aimed to estimate the burden of rotavirus disease in Belgium. In children younger than 7 years of age, rotavirus is predicted to account annually for about 5,600 hospitalisations (676:100,000 children); 26,800 outpatient, general practitioner and paediatrician visits; and about 44,600 episodes for which no medical care is sought. This burden is estimated to represent direct costs of 7.7 million € and indirect costs of 12.8 million €. Rotavirus disease causes a substantial health and economic burden in Belgium.     

Cost of curative pediatric services in a public sector setting

Objective : To estimate the cost of ambulatory (out-patient) and in-patient pediatric health services for the year 1999 provided by All India Institute of Medical Sciences (AIIMS) at all the three levels-primary, secondary and tertiary level.Methods: The costing module developed by Children’s Vaccines Initiative (CVI) was used. This rapid assessment tool focuses on collection of data at macro level by using key informants like doctors, nursing staff, accountant, store keeper, engineer etc. Cost per beneficiary was estimated separately for in-patients and out-patients and was calculated by dividing the total cost of the services by the number of beneficaries for the year 1999. For the out-patient, the beneficiaries were the total out-patient attendees and for the in-patient, it was the total pediatric admissions multiplied by mean duration of stay in days.Results: The cost per out-patient visit was INR.20.2 (US$0.44@1US$=INR.46) at primary level, higher than INR14.5 (US$ 0.31) at the secondary level, while at tertiary level it was INR 33.8 (US$ 0.73). At the primary and secondary level, non-physician cost was more than the physician cost, and for tertiary level, physician cost was much higher than the other costs. There were no inpatient services at primary level. The cost of in-patient services at secondary level was estimated as INR 419.30 (US$ 9.1) per patient per day with a bed occupancy rate of 60%. Two-fifths of the cost was due to nursing and other supportive staff and one fifth due to the doctor costs and overhead costs. The unit cost of INR 928 (US$ 20.2) per patient per day incurred at AIIMS with a bed occupancy rate of 100% was almost twice that of secondary level. In contrast to the secondary level, almost half the total costs at tertiary level was due to the doctors costs.Conclusions: Effective use of resources at lower level of care especially ambulatory care at primary level and inpatient care at secondary level can result in much higher savings for the system and also, the society. These would need to be appropriately strengthened.     

Viral encephalitis of public health significance in India: Current status

Japanese encephalitis (JE) and rabies are 2 viral encephalitis that are of public health importance in India. JE is a zoonosis with the primary cycle occurring in arthropods (mosquito vectors) and vertebrate animals (primarily the pig), man being only an incidental ‘dead end’ host. Outbreaks have been seen in most parts of India except the north west. The disease presents with a prodromal stage, an acute encephalitic stage with coma, convulsions and variable deficits and a convalescent stage. Diagnosis can be made by viral isolation from CSF or brain, or serologic tests such as haemagglutination inhibition test and IgM antibody capture ELISA in CSF and blood. There is no specific treatment. Mortality ranges from 20–50% and almost half the survivors have sequelae. The most effective control measure besides control of mosquitos is vaccination. A killed mouse brain vaccine is being prepared in India and is safe and effective but expensive Rabies is a highly fatal encephalomyelitis primarily occurring in urban dogs and wild animals especially canines. It is endemic in India and affects an estimated 3 per 100,000 persons annually. The patient initially may display bizarre combative behaviour. The disease can be effectively prevented by post exposure vaccination. The nervous tissue vaccine is no longer recommended because of unacceptable neurotoxicity. Three cell culture vaccines are presently available with about equal efficacy     

Surfactant replacement therapy—economic impact

Surfactant replacement is an effective treatment for neonatal respiratory distress syndrome. (RDS). As widespread use of surfactant is becoming a reality, it is important to assess the economic.implications of this new form of therapy. A comparison study was carried out at the Neonatal Intensive Care Unit (NICU) of Northwest Armed Forces Hospital, Saudi Arabia. Among 75 infants who received surfactant for RDS and similar number who were managed during time period just before the surfactant was available, but by set criteria would have made them eligible for surfactant. All other management modalities except surfactant were the same for all these babies. Based on the intensity of monitoring and nursing care required by the baby, the level of care was divided as: Level IIIA, IIIB, Level II, Level I. The cost per day per bed for each level was calculated, taking into account the use of hosptital immovable equipment, personal salaries of nursing, medical, ancillary staff, overheads and maintenance, depreciation and replacement costs. Medications used, procedures done, TPN, oxygen, were all added to individual patient’s total expenditure. 75 infants in the Surfactant group had 62 survivors. They spent a total of 4300 days in hospital, (av 69.35) Out of which 970d (av 15.65 per patient) were ventilated days. There were 56 survivors in the non-surfactant group of 75. They had spent a total of 5023 days in the hospital (av 89.69/patient) out of which 1490 were ventilated days (av 26.60 d). Including the cost of surfactant (two doses), cost of hospital stay for each infant taking the average figures of stay would be SR 118,009.75 per surfactant treated baby and SR 164,070.70 per non-surfactant treated baby. The difference of 46,061 SR is 39.03% more in non-surfactant group. One Saudi rial = 8Rs (approx at the time study was carried out.) Medical care cost varies from place to place. However, it is definitely cost-effective where surfactant is concerned. Quality adjusted life years (QALY) for NICU care compares favourably with cost per QALY of several forms of adult health interventions. Audit, both medical and financial, of these services, at regular intervals is essential.     

Use of computers in pediatrics : basic aspects

Conclusions In this paper I have dealt with some of the common features of computers, and attemped to provide an outline for developing computer systems. One might argue that given other high profile problems and a relatively inexpensive labour market in India, automation in medicine should not be of high profile problems and a relatively inexpensive labour market in India, automation in medicine should not be of high priority. While this point of view may be valid, I think if properly planned and developed to integrate computers into the existing health care facilities, the benefits could be immense, particularly in the fild of medical education, research and patient care monitoring. Although the frustrations during the initiala phase of the ’learning curve’ of computerization may be unavoidable, the final results might make the efforts worthwhile.     

Efficacy and safety of therapeutic nutrition products for home based therapeutic nutrition for severe acute malnutrition: <Emphasis Type="Italic">A systematic review</Emphasis>

Context  

Severe acute malnutrition (SAM) in children is a significant public health problem in India with associated increased morbidity and mortality. The current WHO recommendations on management of SAM are based on facility based treatment. Given the large number of children with SAM in India and the involved costs to the care-provider as well as the care-seeker, incorporation of alternative strategies like home based management of uncomplicated SAM is important. The present review assesses (a) the efficacy and safety of home based management of SAM using ‘therapeutic nutrition products’ or ready to use therapeutic foods (RUTF); and (b) efficacy of these products in comparison with F-100 and home-based diet.     

Cost of neonatal intensive care in a tertiary care center

BACKGROUND: The number of neonatal intensive care units (NICUs) in India has increased substantially over the last decade; yet many more are required. There is limited information on the actual costs of setting up and running an NICU in India. OBJECTIVE: Systematic and comprehensive calculation and analysis of the costs of neonatal intensive care in a tertiary care teaching hospital. METHODS: The costs were compiled by studying the detailed records of various hospital departments and prospectively documenting the costs of drugs, consumables and investigations for a representative group of 30 babies. RESULTS: The total cost of establishing a 16 bed level III tertiary care NICU was Rs 3.78 crore (Rs. 37.8 million, USdollar 860,000) (2003). Equipment cost formed two-thirds of the establishment cost. The running cost of NICU care per patient per day was Rs 5450 (USdollar 125). NICU and ancillary personnel salary comprised the largest proportion of the running costs. The average total cost of care for a baby less than 1000 grams was Rs. 168000 (USdollar 3800), Rs. 88300 (USdollar 2000) for babies 1000 g to 1250 g. and Rs. 41700 (USdollar 950) for those between 1250 to 1500 g. The family had to bear only 25 percent; rest was subsidized. CONCLUSIONS: Equipment and personnel salary form the biggest proportion of establishment and running costs. The costs of treatment for a baby in NICU should be seen in context with costs of other types of health care and the number of useful life years gained.     

Pediatricians’ views about oral health care

Pediatricians and family practitioners have the responsibility of providing the crucial primary care for the children. They are considered to be in a unique position to contribute to the dental health of their young patients. In view of this a study was conducted in Mangalore city (India) to assess pediatricians’ views about oral health care and their advice regarding oral hygiene maintenance. Fifty pediatricians were personally interviewed with a questionnaire. All pediatricians acknowledged their role in oral hygiene maintenance of their patients. This study showed that there is a need for more communication between the two pediatric specialties of medicine and dentistry so as to deliver better child health care.     

Covering the costs of care in neonatal intensive care units.

The continued rise of health care costs, despite private and governmental control efforts, has sustained cost containment as a central issue for health care researchers and policy makers. In keeping with these concerns, the Florida Health Care Cost Containment Board conducted a study of neonatal intensive care units (NICUs) in Florida to ascertain the costs, charges, and net revenues associated with NICU services in individual hospitals, to document cost shifting and cross-subsidization as a means of financing NICU care for indigent populations, and to assess the fiscal impact of NICUs in state-sponsored vs non-state-sponsored Regional Perinatal Intensive Care Center hospitals providing NICU care. Hospitals in the state-sponsored program reported a loss of approximately $16.5 million in contrast to the non-state-sponsored hospitals, which reported a gain of $1 million. Payment being generated by private-pay patients amounted to almost 60% of total revenues but constituted less than one third of the costs in state-sponsored hospitals, indicating a high level of cost shifting. Government support of state-sponsored NICUs, while substantial, has been insufficient; increasing constraints on this funding source would likely worsen the deficit and increase the necessity of cost shifting.     

Current status of iodine deficiency disorders (IDD) and strategy for its control in India

Iodine Deficiency Disorders (IDD) reflects the broad manifestations of iodine deficiency including the implications on reproductive functions and lowering of IQ levels in school aged children. Today, IDD is a public health problem in 130 countries and affects 13% of world’s population. In India, no state is free from iodine deficiency and 200 million people are ‘at risk’ of IDD. Daily consumption of salt fortified with iodine is a proven effective strategy and is the measure stressed by the Government of India. The paper describes the major five phases of the IDD Control Programme in India. The paper describes the major five phases of the IDD Control Programme in India since 1962 and synthesizes the spectrum of activities that significantly attributed to the Universal salt lodisation (USI) efforts launched in 1992. The sustainability of the USI programme is critical since IDD prevalence will rise if programme of salt iodisation weakens. A two pronged strategy needs to be institutionalized for ensuring continued demand for iodised salt, linked to ongoing health, nutrition and education programmes as well as for ensuring supply of quality iodised salt     

Facility Based IMNCI

India has the world’s greatest burden of neonatal and under- five mortality. In 2008, approximately 1.8 million under five children, including 1 million neonates, died. At the current rate of progress, India will not be able to achieve the MDG 4 target of reduction of under- five mortality to 38 per 1,000 live births by 2015. The Reproductive and Child Health programme (RCH) II under the National Rural Health Mission (NRHM) comprehensively integrates interventions that improve child health and addresses factors contributing to infant and under-five mortality. Under the RCH II National Programme—Implementation Plan, IMNCI approach is the major instrument of newborn and child health strategy. IMNCI clinical guidelines focus on assessment, classification and providing treatment according to disease severity. Severe illnesses (red classification) require urgent referral after pre-referral treatment. Further diagnosis and management is dependent on the skills of health workers of the referral hospital. Therefore, capacity building of professionals for providing optimum care for sick children in referral units is an obvious path to optimize the benefits of IMNCI on child survival. With these objectives, F-IMNCI (Facility based IMNCI) package was developed by a committee of experts constituted by the Ministry of Health and Family welfare, Government of India.     

Recognition of the entity “the battered child syndrome” in India

Conclusion In India there is need for the formation of legislation for the protection of the battered child. The law should enforce mandatory reporting which may even prevent the occurence of child abuse. The child’s safety should be the main concern. Everything should be done to prevent repeated trauma. The physcian’s obligation to the court is that unless he takes a firm stand and states his findings and recommendations clearly, the judge will have difficulty in making a reasonable and a fairly valid decision whether or not it is safe for the child to return home. In any event, the physician should not agree to return the child to an environment where even a moderate risk of repetition exists. Should the death of a child for someone’s wickedness be ignored? Formerly at the Department of Pediatrics, Children’s Hospital of Michigan, Wayne State University School of Medicine, Detroit, Michigan U.S.A.     

Production and distribution of a therapeutic nutritional product for severe acute malnutrition in India: Opportunities and challenges

Limited resources for hospitalized treatment of India’s nearly 8 million children with severe acute malnutrition (SAM) make community management of SAM a priority. Capability to produce sufficient quantities of Ready to Use Therapeutic Food (RUTF) is one component of preparedness for community management of SAM. Production of RUTF is a simple process that consists of grinding, mixing and packaging using widely available equipment. Nitrogen flush packaging increases shelf life to 2 years though it is the most expensive and slowest step of the production process. Being a therapeutic product, quality and safety must be ensured including aflatoxin measurement and estimation of micronutrient and macronutrient content consistently. RUTF can be made in India in several production models — (i) Dairy cooperatives and private manufacturers can produce large quantities to meet regional requirements, (ii) small and niche food manufacturers can produce smaller volumes but have a major presence in most parts of India; and (iii) “hand made” RUTF can be made by “village industries” for immediate local consumption. All the ingredients and equipment for RUTF are widely available in India — RUTF is already being produced in India for export. Concerns from various sections of society will need to be heard before community management of SAM using therapeutic, processed nutritional products can begin. Despite apprehensions about processed RUTFs or the sections of the public health community that press for its use, withholding alternative treatment for one of the largest killers of India’s children must not be the option. It is time public health/ medical communities and civil society come together to make effective community management of SAM an immediate reality.     

Primary health care and child survival in India

The Primary Health Care (PHC) has been globally promoted as a comprehensive approach to achieve optimal health status and ‘Health for all’. The PHC approach, although, initially received the attention but failed to meet the expectations of the people in India. The child health programs in India had been started for long as verticals programs, which later on integrated and had been planned in a way to deliver the services through the PHC systems. Nevertheless, the last decade has witnessed many new initiatives for improving child health, specially; a number of strategies under National Rural Health Mission have been implemented to improve child survival- Skilled Birth Attendant and Emergency Obstetric Care, Home Based Newborn Care, Sick newborn care units, Integrated Management of Neonatal and Childhood Illnesses, strengthening Immunization services, setting up Nutritional rehabilitation centers etc. However, for a large proportion of rural population, an effective and efficient PHC system is the only way for service delivery, which still needs more attention. The authors note that although there have been improvements in infrastructure, community level health workers, and availability of the funding etc., the areas like community participation, district level health planning, data for action, inter-sectoral coordination, political commitment, public private partnership, accountability, and the improving health work force and need immediate attention, to strengthen the PHC system in the country, making it more child friendly and contributory in child survival, in India.     

Setting priorities in injury prevention: the application of an incidence based cost model

OBJECTIVES: To make detailed calculations on the direct medical costs of injuries in the Netherlands to support priority setting in prevention. METHODS: A computerised, incidence based model for cost calculations was developed and incidence figures derived from the Dutch Injury Surveillance System (LIS) which provides national estimates of the annual number of patients treated at an emergency department. A comprehensive set of cost elements (that is, health care segments) was obtained from health care registrations and a LIS patient survey. Patients were assigned to specific groups based on LIS characteristics (for example, age, injury type). Average costs per patient group were calculated for each cost element and total costs estimated by adding costs for all patient groups. RESULTS: The direct costs of injury average 2000 guilders per injury patient attending an emergency department. Home and leisure injuries account for over half of the costs, although cost per patient is highest for motor vehicle injuries. Injuries to the lower extremities account for almost half of the total costs and are incurred mainly in the home or recreation. Motor vehicle crashes are the major cause of head injuries. CONCLUSIONS: The model permits continuous and detailed monitoring of injury costs. Estimates can be compiled for any LIS patient group or injury subcategory. The results can be used to rank injuries for prioritisation of prevention by injury categories (for example, traffic, home, or leisure), or by specific scenarios (for example, fall at home).     

Priorities in child health

A noted pediatrician in New Delhi, India, urges fellow pediatricians to promote the health and safeguard the interests of children. He advocates the establishment of comprehensive genetic units in the pediatric departments in teaching hospitals in India to reap the benefits of the genetic revolution. Specifically, advances in molecular genetics have led to advanced diagnostic and therapeutic concepts and uses (e.g., DNA probes to identify various pathogenic antigens and gene therapy). India needs to develop its infrastructure and facilities to acquire technology for diagnosis, monitoring, and providing life support to children with life-threatening conditions. For example, all teaching hospitals in India must set up neonatal and pediatric intensive care units as soon as possible. Since the government and hospital administrators fund expensive technology for coronary care units, postoperative intensive care units, and cancer hospitals, they can also afford to provide neonatal and pediatric intensive care units. Hospital pediatric departments must create extensive child development centers to monitor child development in order to diagnose and treat early neuromotor disability. Pediatricians should develop the art of child care which includes skills in listening, soothing, gaining confidence, explaining, and consoling as well as effective health education. During each visit, they should educate the family about health and nutrition. The lack of political will is the major reason India cannot meet its maternal and child health (MCH) targets. For example, the government allocates less than 2% of the gross national product to health and family welfare programs. The government and physicians pay more attention to expanding cancer and coronary care hospitals than to promoting MCH. Pediatricians should work together to do just that, but improved child health status cannot occur without addressing discrimination against female children.     

Feeding in the PICU

Nutrition plays a vital role in maintaining and enhancing the health of an individual. As mortality within intensive care units declines because of increased expertise and better equipment, attention is being focused on better methods of feeding the critically ill child. Feeding the child is one aspect that has been relegated to the back burner of the typically busy PICU. Evidence that feeding enhances immunity, protects the gut and shortens recovery time forces us to learn to feed our patients in more effective and safer ways. This article reviews the importance of fe eding, especially that of enterai feeding, in the intensive care setting. The reactions of a stressed metabolism are outlined; separate nutritional components are discussed and requirements in specific conditions are given. Parenteral nutrition remains fraught with practical difficulties in India. Metabolic and infective complications are frequent and constant monitoring coupled with the cost of these solutions raises cost beyond affordable levels. Hence the emphasis on enterai feeding, with it’s proven safety, routes of administration and ready availability. The immunity enhancing properties of enterai feeding is another aspect that has gained interest in recent years. Ecoimmunonutrition is a new concept that keeps the ecology of the stressed Gl tract intact while providing adequately balanced formulae along with micronutrients and fibre.     

Characteristics of Burkitt’s lymphoma in India

Clinical presentation of Burkitt’s lymphoma in India does not resemble either endemic or non-endemic areas. Jaw involvement was observed in 27 of 52 (51·9%) cases with Burkitt’s lymphoma on retrospective analysis of published cases along with 14 of our cases. Higher incidence of jaw involvement is unusual as compared to the pattern of Burkitt’s lymphoma of non-endemic areas of the world. Abdominal involvement was seen in 30 of 52 patients (58·8%) in India. Burkitt’s lymphoma in India presents with jaw and abdominal involvement in almost equal number and this may be the third mode of clinical presentation.