The burden of community-acquired pneumonia in Spain.

BACKGROUND: Community-acquired pneumonia accounts for a large number of hospitalizations and deaths in developed countries. METHODS: Data for Spain were obtained from the national surveillance system for hospital data and comprises all hospital discharges for pneumonia reported during a two-year period. RESULTS: The annual incidence of hospitalization for pneumonia was 160 per 100,000 population. Incidence of hospitalization, mortality, average length of stay and case-mortality rate were higher in persons > or = 65 years of age. The annual cost of these hospitalizations was 115 million ECUs (1 ECU = 1.19 US Dollars). CONCLUSION: Community-acquired pneumonia accounts for 53,000 hospitalizations per year in Spain, and this imposes a large economic cost on the National Health-care System.     

Influenza vaccination coverage in the geriatric population of the State of Geneva, Switzerland

Background: In Switzerland, every year the Federal Office ofPublic Health publishes recommendations for the use of influenzavaccine in people over 65 years, patients of all ages sufferingfrom chronic conditions or immunosuppression, families of thelatter and health professionals. However, prior to the presentstudy, there has been no evaluation of the degree to which theserecommendations are implemented. The purpose of the survey describedin this article was to evaluate flu vaccination coverage ofthe geriatric population living in the community, to obtainqualitative information on the motivation for receiving vaccinationand to understand the network of communication on flu prevention.Methods: The study was performed on a random sample of 1,200residents of the State of Geneva aged 65 years or older. Itinvolved a mail questionnaire and semi-structured telephoneinterviews on a subsample of respondents. Results: The estimatedvaccination coverage for 1994 was equal to 35.5% in persons65 years-old or older. Receiving information from a physicianwas the major determinant in the decision to be vaccinated.Misconceptions about flu were common. Conclusions: The resultsof this study indicate that national recommendations concerningvaccination of elderly people are insufficiently observed inthe State of Geneva. It is necessary to reinforce preventivemessages that explain why flu vaccination should be performed.These messages should aim at correcting and completing elementsof information already present in the at-risk population.     

安徽省疾控系统流感疫苗管理和使用现况调查

目的了解安徽省疾病预防控制机构流感疫苗管理和使用情况,为制定流感大流行防控策略提供依据。方法设计调查表调查全省县（区）级疾控机构,Epidata录入数据,用SPSS12.0软件进行统计分析。结果96家县区级疾控中心中,90家从上级疾控中心购置疫苗,占93.7%。仅2家将流感疫苗接种纳入医保范畴,占4.2%;仅1家制定流感疫苗接种减免政策,占2.1%。疫苗接种对象主要为婴幼儿和中小学生。2008年出库成人型疫苗197 691份,实际接种193 984人份;出库儿童型疫苗259 253份,实际接种258 199份;2008年全省儿童流感疫苗接种率为0.1011%,成人接种率为0.0030%。结论安徽省重点人群流感疫苗接种率低,应提高重点人群的流感疫苗接种率。     

Influenza vaccination among the elderly Spanish population: trend from 1993 to 2003 and vaccination-related factors

BACKGROUND: Influenza is an important public health problem that particularly affects elderly subjects and influenza vaccination is a safe, effective and efficient method for prevention of influenza-related complications in elderly individuals with or without underlying chronic conditions. This study aims to analyze adjusted time trends in the coverage of influenza vaccination among elderly Spanish subjects and to identify which variables were associated with the probability of having been vaccinated in 2003. METHODS: We undertook a cross-sectional study using data of individuals aged >/=65 years drawn from the 1993, 1995, 1997, 2001, and 2003 Spanish National Health Surveys. The answer to the question 'Did you have a 'flu shot in the latest campaign' was used as the dependent variable, and socio-demographic and health-related characteristics were analyzed as independent variables. Coverage of vaccination for each year was adjusted by the direct method for both age and gender. Multivariate logistic regression was used to estimate the independent effect of variables on the receipt of influenza vaccine. RESULTS: 15 989 records were analyzed. Adjusted influenza coverage increased from 50.1% in 1993 to 63.7% in 2003 (P < 0.001). The variables that were significantly associated with a higher likelihood of being vaccinated were older age, suffering a chronic disease, residence in towns with <10 000 inhabitants, 'worse' self-perceived health and non-smokers. CONCLUSIONS: Coverage among the Spanish elderly has increased significantly from 1993 to 2003. Still, there is room for improvement, particularly, among the subjects with 'good' self-perceived health, those with no concomitant medical conditions, and smokers.     

Declining prevalence of injection as main route of administration among heroin users treated in Spain, 1991-1993

The objetive of this study was to analyse the temporal and geographictrends and the factors associated with the prevalence of heroininjection (HI) in persons treated for the first time for heroinabuse/dependence in Spain in 1991–1993. The prevalenceof HI was studied in 54,132 admissions to treatment reportedto the State Information System on Drug Abuse. The factors associatedwith HI prevalence were studied by stratified analysis and logisticregression. Regions with similar prevalences were grouped togetherbased on correspondence analysis. The HI prevalence declinedprogressively by year (50% in 1991, 43% in 1992 and 38% in 1993).The regions were grouped into 3 geographic areas, with risingprevalences in the southwest-northeast. Region was the factormost strongly asociated with HI, with an OR of 6.17 in the highprevalence group as compared with the low prevalence group.A declining trend of HI was seen with the more recent year offirst use (OR of 0.15 for those beginning use in the years 1991–1993as compared with those who began before 1982), later age atfirst use and increasing years of use. Male sex and cocaineuse were associated with higher HI. Chasing is progressivelyreplacing injection as a route of heroin administration becausenew users primarily use this route and probably because themost common transition is from injecting to chasing. The impactof the HIV epidemic and control programmes does not sufficientlyexplain this phenomenon. The main explanatory factors couldbe regional differences in the subculture of drug use or inthe heroin market.     

Examining geographic patterns of mortality: the atlas of mortality in small areas in Spain (1987-1995)

BACKGROUND: Small-area mortality atlases have been demonstrated to be a useful tool for both showing general geographical patterns in mortality data and identifying specific high-risk locations. In Spain no study has so far systematically examined geographic patterns of small-area mortality for the main causes of death. This paper presents the main features, contents and potential uses of the Spanish Atlas of Mortality in small areas (1987-1995). METHODS: Population data for 2,218 small areas were drawn from the 1991 Census. Aggregated mortality data for 14 specific causes of death for the period 1987-1995 were obtained for each small area. Empirical Bayes-model-based estimates of age-adjusted relative risk were displayed in small-area maps for each cause/gender/age group (0-64 or 65 and over) combination using the same range of values (i.e. septiles) and colour schemes. RESULTS: The 'Spanish Atlas of Mortality' includes multiple choropleth (area-shaded) small-area maps and graphs to answer different questions about the data. The atlas is divided into three main sections. Section 1 includes the methods and comments on the main maps. Section 2 presents a two-page layout for each leading cause of death by gender including 1) a large map with relative risk estimates, 2) a map that indicates high- and low-risk small areas, 3) a graph with median and interquartile range of relative risk estimates for 17 large regions of Spain, and 4) relative-risk maps for two age groups. Section 3 provides specific information on the geographical units of analysis, statistical methods and other supplemental maps. CONCLUSION: The 'Spanish Atlas of Mortality' is a useful tool for examining geographical patterns of mortality risk and identifying specific high-risk areas. Mortality patterns displayed in the atlas may have important implications for research and social/health policy planning purposes.     

Epidemiology and cost of treatment of genital warts in Spain

Background: Genital warts (GW) are common and increasing inyoung people. Ninety percent of GW are due to Human Papillomavirus(HPV) types 6 and 11. The objective of this study was to assessthe epidemiology and management costs associated with GW inSpain. Methods: A 1-year (2005) retrospective observational study wasperformed among a sample of gynaecologists, dermatologists andurologists in six autonomous regions in Spain. Men and womenwith newly diagnosed, recurrent or resistant GW were included.We estimated the incidence (new and recurrent cases) and prevalence(also including resistant cases) of GW. Healthcare resourceuse were collected and combined with unit costs to assess themean cost of GW management per patient. These figures were extrapolatedto the 14- to 64-year-old Spanish population to estimate thetotal cost of GW management from the Third Party Payer (TPP)and societal perspectives. Results: The overall annual incidence of GW was estimated at160.4 cases per 100 000. Overall prevalence was calculated as182.1 cases per 100 000, corresponding to 56 446 GW cases annually(14- to 64-year-old population). The mean management cost was833 and 1056 per patient from the TPP and societal perspective,respectively. The overall annual cost was estimated at 47 millionand 59.6 million, from the TPP and societal perspective, respectively. Conclusion: This study provides a first overview of the burdenof GW in Spain. A quadrivalent HPV vaccine that prevents HPV6, 11, 16, 18 related diseases will have the potential to significantlydecrease the socio-economic burden associated with GW in Spain.     

Coverages and factors associated with influenza vaccination among subjects with chronic respiratory diseases in Spain

BACKGROUND: The main influenza complications particularly affect patients over the age of 65 years and those with associated chronic diseases, such as respiratory disorders. This study aims to assess vaccination coverage among Spanish children and adults with chronic respiratory diseases (CRDs), and to describe the factors associated with vaccination in 2003. METHODS: We analysed 28,113 records of individuals (6869 children and 21,244 adults) included in the Spanish National Health Survey (NHS) for 2003. As a dependent variable, we used the reply ('yes' or 'no') to the question: 'Did you have a 'flu shot in the latest campaign?' We calculated influenza vaccine coverage as the percentage of individuals with a respiratory disorder (asthma and/or chronic bronchitis and/or emphysema) who reported having been vaccinated against influenza in the most recent campaign. We analysed the influence of sociodemographic, health-status, medical visits and lifestyle variables on vaccination. RESULTS: Vaccination coverage was 19.9% in children and 54.7% in adults suffering CRD. In both age groups, coverages were significantly higher than those observed for non-CRD sufferers. Among adults, older age, not smoking and medical visits to their physician in the preceding 2 weeks were the variables independently and significantly associated with a higher likelihood of receiving the vaccine. Among children, financial factors influence vaccination. CONCLUSIONS: Vaccination coverage among children with CRDs is very low. Also among adult CRD sufferers, vaccination remains below the desired level, thereby making it necessary for strategies to be implemented aimed at improving the use of influenza vaccine.     

Pre-natal care and prevention of low birth weight: A case-control study in southern Spain

A national policy for improving pre-natal care was applied throughoutAndalusia (southern Spain) in 1984. We report the results ofan evaluation of this health care programme as regards the preventionof low birth weight. Two case-control studies in a hospitalsetting were performed: one before the programme was implemented(1981–1982) and the second one 6 years after the programme(1990–1993). A total of 179 cases and 395 controls forthe period 1981–1982 and 251 cases and 381 controls for1990–1993 were selected. Pre-natal care was assessed onthe basis of the number of pre-natal care visits, the date ofthe first visit and an American composite index to adjust forgestational age. Multiple-factor adjusted odds ratios (OR) andtheir 95% confidence intervals (CI) were estimated using logisticregression analysis. The use of pre-natal care significantlyimproved overtime: the proportion of women receiving no pre-natalcare decreased from over 30% to less than 5% and the proportionof women starting pre-natal care in the first trimester for1990–1993 was 3 times the figure for 1981–1982.In the 1981–1982 case-control study, pre-natal care wasnot related to low birth weight risk. In the 1990–1993case-control study, a clear and significant trend was observedbetween the number of pre-natal care visits and the adequacyof care according to the composite index and the risk of lowbirth weight. When these relationships were analysed stratifyingby gestational age, a significant trend was found between pre-natalcare and pre-term low birth weight. The results suggest thatthe present Andalusian programme helps prevent pre-term lowbirth weight.     

Influenza vaccines in adults

Available influenza vaccines contain inactivated viruses, either whole or in parts, and are administered parenterally or intranasally. Their composition varies yearly because of viral antigenic shifts and drifts. Vaccines with a composition matching yearly World Health Organization recommendations are 72% [95% confidence interval (CI) = 54-83%] efficacious (prevention of influenza cases caused by influenza viruses A and B). Their effectiveness [capacity to prevent clinical influenza, or influenza-like illness (ILI)] is lower, at 37% (95% CI = 18-52%). A decision to vaccinate an adult population has to take into account the efficacy of the vaccines and their effectiveness (the likely proportion of ILI caused by influenza A and B viruses, amenable to prevention by vaccination), as well as costs and likely compliance. As the yearly levels of circulating A and B viruses are difficult to predict during the decision time for a vaccination campaign, there is a considerable element of uncertainty regarding the likely effectiveness of 'this year's' vaccine.     

Translating evidence into practice. The case of influenza vaccination.

A problem common to all health care systems remains the translation of robust evidence into effective practice. Influenza vaccination has been reported to be an effective public health care intervention, but guidelines on coverage and subsequent uptake rates for vaccination across European countries vary substantially. One challenge therefore is to evaluate how effective different implementation mechanisms may be in improving overall vaccination rates for target populations across Europe.     

北京市房山区人群禽流感病毒感染风险分析

目的评估北京市房山区人感染禽流感发生风险,为制定有效的防控措施提供科学依据。方法2017-04-23,对北京市房山区首例人感染H7N9禽流感病例感染来源进行调查,并通过疫情强化监测、禽流感血清学监测和禽流感外环境监测建立禽流感监测体系,对咽拭子标本和外环境标本进行禽流感病毒核酸检测,对血清标本进行抗体滴度检测,并进行χ~2检验,检验水准α=0.05。结果禽流感疫情调查提示病例感染来源于从流动商贩买的鸡。强化监测发现了1例H9N2禽流感确诊病例。采集血清标本455份,阳性44份(9.67%),其中阳性率最高为H5N6,其次为H9N2。野生候鸟栖息地人员禽流感血清抗体检测阳性率高于禽类、猪类从业人员,差异有统计学意义(χ^2=10.278,P<0.05)。禽流感及野禽外环境监测共采集标本960份,检出禽流感阳性标本13件(1.35%),全部源于活禽买卖宰杀摊位。禽咽拭子肛拭子阳性检出率最高,为27.78%,其次为宰杀或摆放禽肉案板表面涂抹样本,阳性率16.28%。结论北京市房山区发生了H7N9和H9N2禽流感疫情,禽流感环境监测和血清学监测均发现了禽流感病毒,流动活禽交易或宰杀是人群感染禽流感的主要风险来源。应加强农业、卫生、工商等部门联防联控,采取积极措施防控禽流感。     

Gender and educational differences in smoking initiation rates in Spain from 1948 to 1992

BACKGROUND: The pattern of smoking initiation is of importance in understanding the prevalence of smoking and future trends in tobacco-related diseases. OBJECTIVE: To analyse trends of cigarette smoking initiation rates by sex and educational level in Spain. METHODS: Pooled data from the 1993, 1995 and 1997 Spanish National Health Interview Surveys were used (16,365 males and 17,478 females aged >15 years). The age and smoking status of each subject were reconstructed for five calendar periods (1948-1952, 1958-1962, 1968-1972, 1978-1982, 1988-1992). Age-specific (10 to 24 years old) smoking initiation rates were calculated for males and females, and according to level of education (high education: university and secondary school; low education: primary and less than primary). RESULTS: Among males, there was a trend towards earlier age at start of smoking and higher initiation rates between 1958 and 1982, and a subsequent decline in initiation rates, more apparent in males with a higher level of education. Smoking initiation among females was rare until the 1960s, and from the period 1968-1972 onwards a converging pattern with that of males was observed. Women with a higher level of education started smoking before women with low education, but this pattern changed over the period 1978-1982, with higher initiation rates among less educated women during the last period studied. CONCLUSIONS: These results help to characterize the tobacco epidemic in Spain, now at the end of stage 3. The observations are in agreement with diffusion-of-innovations theory and the social and economic changes from the 1960s onwards in Spain.     

Social, demographic and attitudinal correlates of AIDS: Knowledge in the general population of Spain

The association between AIDS knowledge and various social, demographicand attitudinal variables was examined to elicit a better understandingof what makes some individuals more knowledgeable than othersabout HIV infection. A total of 1,800 individuals were surveyedin Madrid (Spain). Results show that having a low level of education(OR_adj = 4.3, 95% Cl 3.0, 6.2), being older than 45 years (OR_adj= 3.3, 95% Cl 2.4, 4.5) and being on the right of the politicalspectrum (OR_adj = 2.7, 95% Cl 1.8, 4.0) increases the odds ofhaving a low level of AIDS knowledge. Given the educationaland political characteristics of those less knowledgeable, healtheducation efforts need to convey simple and understandable messagesadapted to their way of thinking. Results also show that lackof knowledge is associated with fear. A catastrophic perceptionof the magnitude of the epidemic (OR_adj = 1.9, 95% Cl 1.4, 2.5)is strongly associated with low knowledge. However, lack ofknowledge is associated not only with fear but also with thesupport of coercive measures to prevent the spread of HIV Infection.Therefore, health education messages that incite fear of AIDSand feelings of vulnerability may increase coercion as wellas affecting AIDS knowledge.     

社区医生对接种肺炎球菌疫苗的知信行及影响因素研究

  目的  了解2022年浙江省 ≥ 50岁居民流感和肺炎球菌疫苗接种情况及其影响因素,为有效提高该地区中老年人群流感和肺炎球菌疫苗的接种率提供参考依据。  方法  于2022年6月采用多阶段随机抽样方法在浙江省7个区/县35个社区/村抽取2200名 ≥ 50岁居民对其流感和肺炎球菌疫苗接种情况进行问卷调查,并采用多因素非条件logistic回归模型分析影响浙江省 ≥ 50岁居民流感和肺炎球菌疫苗接种情况的主要因素。  结果  浙江省最终纳入分析的2100名 ≥ 50岁居民中,接种流感疫苗和肺炎球菌疫苗者分别为776人和116人,流感疫苗和肺炎球菌疫苗接种率分别为36.95%和5.52%。多因素非条件logistic回归分析结果显示,高中及以上文化程度、知晓流感及其疫苗知识、享受流感疫苗免费接种政策和有医生推荐接种的居民更意愿接种流感疫苗;享受肺炎球菌疫苗免费接种政策和有医生推荐接种的居民更意愿接种肺炎球菌疫苗。浙江省 ≥ 50岁居民接种流感疫苗的主要原因为社区通知接种[590人次（76.03%）]、家人建议接种[400人次（51.55%）]和自己想要预防疾病[350人次（45.49%）],未接种的主要原因为对疫苗不了解[816人次（61.63%）]、担心有副作用[321人次（24.24%）]和感觉没有必要[296人次（22.36%）];接种肺炎球菌疫苗的主要原因为社区通知接种[85人次（73.28%）]、家人建议接种[67人次（57.76%）]和自己想要预防疾病[51人次（43.97%）],未接种的主要原因为对疫苗不了解[1270人次（64.01%）]、感觉没有必要[450人次（22.68%）]和担心有副作用[442人（22.28%）]。  结论   2022年浙江省 ≥ 50岁居民流感和肺炎球菌疫苗接种率均较低,是否享受疫苗免费接种政策和是否有医生推荐接种疫苗是该地区 ≥ 50岁居民流感和肺炎球菌疫苗接种情况的共同影响因素。     

Influenza outbreak control in confined settings

Influenza may rapidly disseminate within populations living in confined settings, causing considerable morbidity and disrupting daily activities. We describe an influenza A outbreak on a military base where 3,000 young adults, most of whom were unvaccinated, lived in close daily contact. Visits to the base clinic by 48 persons with acute respiratory illness within 2 days allowed early identification of this outbreak and prompted immediate epidemiologic investigation. Overall, 85 personnel (2.83% of base population) met the case definition for influenzalike illness. On-site laboratory confirmation with field detection kits, rapid implementation of respiratory illness control protocols, and a mass vaccination campaign were applied to limit disease dissemination. The outbreak was halted 14 days after the mass vaccination campaign was completed. We review the control measures available for controlling influenza outbreaks in confined settings and discuss the role of rapid mass vaccination within this context.     

山东省滨州市儿童流感疫苗接种率的变化趋势及影响因素分析

目的 对2015-2017年山东省滨州市5岁以下儿童10个接种门诊流感疫苗接种率现状进行调查分析,为儿童流感疫苗接种提供数据资料。方法 采用自制的调查问卷对滨州市480名5岁以下儿童父母进行问卷调查,并进行回顾性分析,采用Logistic回归模型分析5岁以下儿童流感疫苗接种的影响因素。结果 滨州市10个接种门诊5岁以下儿童流感疫苗接种率由2015年的42.29%(203/480)下降到2017年的20.21%(97/480);其中3~5岁以下儿童流感疫苗接种率由2015年的26.87%(129/480)下降到2017年的13.13%(63/480),3岁以下婴儿流感疫苗接种率由2015年的15.42%(74/480)下降到2017年的7.08%(34/480)均具有明显的下降趋势(χ²=11.073,14.312,P<0.05)。对儿童父母的问卷调查结果显示:不同文化程度、家庭人均月收入、职业、户籍所在地、是否接种过流感疫苗和支付医疗费用方式是影响儿童流感疫苗接种的主要因素,经多因素分析结果发现,父母文化程度初中以上(高中/中专/高职OR=1.49,95%CI: 1.08～2.04;本科/大专OR=2.45,95%CI: 1.61～3.73;硕士及以上OR=3.90,95%CI: 1.70～8.87)、家庭月人均收入3 000元及以上(3 000～5 999元OR=1.35,95%CI:1.07～1.71;≥6 000元OR=2.37,95%CI: 1.25～4.51)、职业为机关企事业单位员工(OR=3.15,95%CI: 1.71～5.80)、对流感疫苗知识知晓(OR=2.24,95%CI: 1.56～3.21)是影响5岁以下儿童家长流感疫苗接种率的重要因素(P<0.001)。结论 文化程度、家庭月人均收入、是否接种过流感疫苗是影响婴幼儿流感疫苗接种率的重要影响因素,应多层次开展有关流感及其疫苗接种知识的宣教。     

Fc functional antibody responses to adjuvanted versus unadjuvanted seasonal influenza vaccination in community-dwelling older adults

BackgroundSeasonal influenza vaccination with a standard trivalent influenza vaccine (TIV) induces a modest, and cross-reactive, Fc functional antibody response in older adults. Recent improvements to influenza vaccines include a quadrivalent influenza vaccine (QIV) and a TIV adjuvanted with the squalene-based oil-in-water emulsion MF59.MethodsPre- and post-vaccination serum samples from older adults vaccinated with QIV (n = 27) and adjuvanted TIV (n = 44) were studied using hemagglutination inhibition (HAI) assays and dimeric Fc-gamma receptor IIIa binding ELISAs, as a surrogate of antibody-dependent cellular cytotoxicity (ADCC).ResultsWe found that the unadjuvanted QIV elicited a stronger HAI response against the H1N1 vaccine virus than the adjuvanted TIV. Post-vaccination levels of HA-specific ADCC antibodies were similar for older adults vaccinated with QIV and adjuvanted TIV. The ADCC response to influenza vaccination was largely determined by pre-vaccination or baseline levels of these antibodies, with older adults with low baseline levels of ADCC activity demonstrating greater post-vaccination rises.ConclusionsIn this cohort of community-dwelling older adults, the QIV was at least as good as the adjuvanted TIV in the induction of ADCC and HAI responses. Further studies on how these antibody responses translate to efficacy in preventing influenza infections are warranted.     

Cost-Effectiveness of Quadrivalent Versus Trivalent Influenza Vaccination in the Dutch National Influenza Prevention Program

ObjectivesAs of 2019, quadrivalent influenza vaccine (QIV) has replaced trivalent influenza vaccine (TIV) in the national immunization program in The Netherlands. Target groups are individuals of 60+ years of age and those with chronic diseases. The objective was to estimate the incremental break-even price of QIV over TIV at a threshold of €20 000 per quality-adjusted life-year (QALY).MethodsAn age-structured compartmental dynamic model was adapted for The Netherlands to assess health outcomes and associated costs of vaccinating all individuals at higher risk for influenza with QIV instead of TIV over the seasons 2010 to 2018. Influenza incidence rates were derived from a global database. Other parameters (probabilities, QALYs and costs) were extracted from the literature and applied according to Dutch guidelines. A threshold of €20 000 per QALY was applied to estimate the incremental break-even prices of QIV versus TIV. Sensitivity analyses were performed to test the robustness of the model outcomes.ResultsRetrospectively, vaccination with QIV instead of TIV could have prevented on average 9500 symptomatic influenza cases, 2130 outpatient visits, 84 hospitalizations, and 38 deaths per year over the seasons 2010 to 2018. This translates into 385 QALYs and 398 life-years potentially gained. On average, totals of €431 527 direct and €2 388 810 indirect costs could have been saved each year.ConclusionUsing QIV over TIV during the influenza seasons 2010 to 2018 would have been cost-effective at an incremental price of maximally €3.81 (95% confidence interval, €3.26-4.31). Sensitivity analysis showed consistent findings on the incremental break-even price in the same range.