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

• 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.

Nationwide outbreak

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 interventionoLocal health department

cost • New River Health District

oLocal clinical facilities cost• Lewis Galeo Montgomeryo Salemo Pulaski

• Roanoke Carillion

• Cost of controloNo 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 $16,748.5 Director of Health District $6,746.9

Planner $1,558.7 EH Manager $511.0 Clerical $372.8 Admin $240.0 Nurse Epi $575.5 Volunteers $3,739.5 Total $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 EstimationDALY 2.87+97.65=100.52   

YLL(With treatment)# of potential casesCase fatalityAverage life expectancy in VirginiaAverage age of exposed patients 

YLL (Without treatment)# of potential casesCase fatalityAverage life expectancy in VirginiaAverage age of exposed patients

 YLL

10.15 years7 10% 79 years57 years 107.8 years770%79 years57 years |10.15-107.8|=97.65

YLD(With treatment)Disability weight Average duration of Disease 

YLD(Without treatment) 

YLD

2.87 years0.615, [0.613,0.616]8 months[3 months- 1yr] 0 2.87

Incremental Cost Effectiveness Ratio

=

= = $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

nargesd@vt.edu

Benefits

• DALY = Years of Life Lost (YLL) + Years of Life Lost due to Disability (YLD)

• YLL= Number of potential cases x case fatality

x

(Average life expectancy- Average Age at time of death)

• YLD = Number of cases

x

Disability Weight

x

Average duration of the disease until remission or death