Costs associated with delivering HPV vaccination in the context of the first year demonstration programme in southern Mozambique.

BACKGROUND: In Mozambique cervical cancer is a public health threat, due to its high incidence and limited access to early diagnosis of precancerous lesions. International organisations are supporting the introduction of human papillomavirus (HPV) vaccines in low- and middle-income countries. Some of these countries recently conducted demonstration programmes, which included evaluation of acceptability, coverage, and practicality of implementation and of integration in existing programmes. Information on costs of delivering the vaccine is needed to overcome the challenges of reaching vaccine potential recipients in rural and remote areas. METHODS: We estimated the financial and economic costs of delivering HPV vaccination to ten-year-old girls at schools for the first vaccination cycle of the demonstration programme in the Manhiça district (southern Mozambique), delivered throughout 2014. We also estimated costs of an alternative scenario with a reduced number of doses and personnel, which was analogous to the second vaccination cycle delivered throughout 2015. Cost estimates followed a micro-costing approach and included interviews with key informants at different administrative levels through the administration of standard questionnaires developed by the World Health Organisation. RESULTS: Considering only data from the first vaccination cycle (2014), which consisted in the administration of three doses, the average economic cost was US$17.59 per dose and US$52.29 per fully-immunised girl (FIG). Financial cost per dose (US$6.07) and per FIG (US$17.95) were substantially lower. The economic cost was US$15.53 per dose and US$31.14 per FIG when estimating an alternative cost scenario with reduced number of doses and personnel. CONCLUSIONS: The average economic cost per dose was lower than the ones recently reported for low- and middle-income countries. However, our estimation of the financial cost per FIG was higher than the ones observed elsewhere (ranging from US$2.49 in India to US$20.36 in Vietnam) due to the high percentage of out-of-school girls which, reduced vaccine coverage and, therefore, reduced the denominator. Due to budget constraints, if Mozambique is to implement nation-wide HPV vaccination targeted to ten-year-old girls at schools, a reduction in personnel costs should be operated either by restricting the outreach vaccinator team or the number of supervision visits

Patients' costs, socio-economic and health system aspects associated with malaria in pregnancy in an endemic area of Colombia.

Malaria in pregnancy threatens birth outcomes and the health of women and their newborns. This is also the case in low transmission areas, such as Colombia, where Plasmodium vivax is the dominant parasite species. Within the Colombian health system, which underwent major reforms in the 90s, malaria treatment is provided free of charge to patients. However, patients still incur costs, such as transportation and value of time lost due to the disease. We estimated such costs among 40 pregnant women with clinical malaria (30% Plasmodium falciparum, 70% Plasmodium vivax) in the municipality of Tierralta, Northern Colombia. In a cross-sectional study, women were interviewed after an outpatient or inpatient laboratory confirmed malaria episode. Women were asked to report all types of cost incurred before (including prevention), during and immediately after the contact with the health facility. Median total cost was over 16US$for an outpatient visit, rising to nearly 30US$ if other treatments were sought before reaching the health facility. Median total inpatient cost was 26US$or 54US$ depending on whether costs incurred prior to admission were excluded or included. For both outpatients and inpatients, direct costs were largely due to transportation and indirect costs constituted the largest share of total costs. Estimated costs are likely to represent only one of the constraints that women face when seeking treatment in an area characterized, at the time of the study, by armed conflict, displacement, and high vulnerability of indigenous women, the group at highest risk of malaria. Importantly, the Colombian peace process, which culminated with the cease-fire in August 2016, may have a positive impact on achieving universal access to healthcare in conflict areas. The current study can inform malaria elimination initiatives in Colombia

Age interactions in the development of naturally acquired immunity to Plasmodium falciparum and its clinical presentation

Background Naturally acquired malaria immunity has many determinants and, in the absence of immunological markers of protection, studies assessing malaria incidence through clinical endpoints remain an approach to defining immunity acquisition. We investigated the role of age in disease incidence and the effects of chemoprophylaxis on clinical immunity development to Plasmodium falciparum during a randomised controlled trial. Methods and Findings A total of 415 Tanzanian infants were randomly assigned to receive weekly malaria prophylaxis with Deltaprim (3.125 mg of pyrimethamine plus 25 mg of dapsone) or placebo between the ages of 2 and 12 mo. Children were followed up until 4 y of age. Uncomplicated febrile malaria, severe malaria, and anaemia morbidity were assessed through hospital-based passive surveillance. Compared with the group of control participants, there was a marked reduction in the incidence of clinical malaria, severe malaria, and anaemia in the group of children who had received chemoprophylaxis during the first year of life. After discontinuing the intervention, there was a significant increase in the incidence of clinical malaria for 2 y. The cumulative rates of clinical malaria, by age 4 y, were slightly higher in the group of children who had previously received chemoprophylaxis: 3.22 episodes versus 3.02 episodes in the group of control participants; rate difference 0.20 (95% confidence interval [CI]: −0.21 to 0.59). By age 4 y, the cumulative rates of severe malaria, however, were slightly lower in chemosuppressed children (0.47 versus 0.59) (rate difference −0.12 [95% CI: −0.27 to 0.03]). The number of episodes of anaemia was also slightly lower in chemosuppressed children by age 4y: 0.93 episodes (95% CI: 0.79 to 0.97) versus 1.12 episodes in the group of control participants (95% CI: 0.97 to 1.28) (rate difference −0.19 [95% CI: −0.40 to 0.01]), respectively. Conclusions Reducing exposure to P. falciparum antigens through chemoprophylaxis early in life can delay immunity acquisition. Infants appear to acquire immunity faster than older children, but have a higher risk of developing severe forms of malaria and anaemia. These findings provide insight on the interplay between immunity and exposure-reduction interventions

Paleogene succession underlying the La Espina Thrust (boundary between the Cantabrian and West-asturianleonese zones). Tectonic implications

Este artículo da a conocer la existencia de una sucesión paleógena, datada mediante su contenido polínico, bajo el cabalgamiento que separa las zonas Cantábrica y Asturoccidental-leonesa. Esta sucesión paleógena se apoya sobre arenas y arcillas con facies similares a unidades cretácicas como la Formación Utrillas. El cobijamiento de dicha sucesión por el cabalgamiento varisco antes mencionado, implica que éste fue reactivado durante la deformación AlpinaThis paper describes the stratigraphy and structural setting of a new outcrop of Paleogene sediments, whose age has been determined from their pollen content. These sediments overlie sands and clays of presumed Cretaceous age and underlie the La Espina Thrust, that is the boundary between two Variscan geological domains: the Cantabrian and Westasturian-leonese zones. The Alpine deformation caused reactivation of the La Espina Variscan Thrust as a reverse faul

VAR2CSA Signatures of High Plasmodium falciparum Parasitemia in the Placenta

Plasmodium falciparum infected erythrocytes (IE) accumulate in the placenta through the interaction between Duffy-binding like (DBL) domains of parasite-encoded ligand VAR2CSA and chondroitin sulphate-A (CSA) receptor. Polymorphisms in these domains, including DBL2X and DBL3X, may affect their antigenicity or CSA-binding affinity, eventually increasing parasitemia and its adverse effects on pregnancy outcomes. A total of 373 DBL2X and 328 DBL3X sequences were obtained from transcripts of 20 placental isolates infecting Mozambican women, resulting in 176 DBL2X and 191 DBL3X unique sequences at the protein level. Sequence alignments were divided in segments containing combinations of correlated polymorphisms and the association of segment sequences with placental parasite density was tested using Bonferroni corrected regression models, taking into consideration the weight of each sequence in the infection. Three DBL2X and three DBL3X segments contained signatures of high parasite density (P<0.003) that were highly prevalent in the parasite population (49–91%). Identified regions included a flexible loop that contributes to DBL3X-CSA interaction and two DBL3X motifs with evidence of positive natural selection. Limited antibody responses against signatures of high parasite density among malaria-exposed pregnant women could not explain the increased placental parasitemia. These results suggest that a higher binding efficiency to CSA rather than reduced antigenicity might provide a biological advantage to parasites with high parasite density signatures in VAR2CSA. Sequences contributing to high parasitemia may be critical for the functional characterization of VAR2CSA and the development of tools against placental malaria

X-ray observations of sub-mm LABOCA galaxies in the eCDFS

We explore the X-ray properties of the 126 sub-mm galaxies (SMGs) of the LABOCA survey in the CDFS and the eCDFS regions. SMGs are believed to experience massive episodes of star-formation. Our goal is to examine whether star-formation coexists with AGN activity, determine the fraction of highly obscured AGN and finally to obtain an idea of the dominant power-mechanism in these sources. Using Spitzer and radio arc-second positions for the SMGs, we find 14 sources with significant X-ray detections. For most of these there are only photometric redshifts available, with their median redshift being ~2.3. Taking into account only the CDFS area which has the deepest X-ray observations, we estimate an X-ray AGN fraction of <26+/-9 % among SMGs. The X-ray spectral properties of the majority of the X-ray AGN which are associated with SMGs are consistent with high obscuration, 10^23 cm-2, but there is no unambiguous evidence for the presence of Compton-thick sources. Detailed Spectral Energy Distribution fittings show that the bulk of total IR luminosity originates in star-forming processes, although a torus component is usually present. Finally, stacking analysis of the X-ray undetected SMGs reveals a signal in the soft (0.5-2 keV) and marginally in the hard (2-5 keV) X-ray band. The hardness ratio of the stacked signal is relatively soft (-0.40+/-0.10) corresponding to a photon index of ~1.6. This argues against a high fraction of Compton-thick sources among the X-ray undetected SMGs.Comment: 13 pages, to appear in A&

VAR2CSA signatures of high Plasmodium falciparum parasitemia in the placenta.

Plasmodium falciparum infected erythrocytes (IE) accumulate in the placenta through the interaction between Duffy-binding like (DBL) domains of parasite-encoded ligand VAR2CSA and chondroitin sulphate-A (CSA) receptor. Polymorphisms in these domains, including DBL2X and DBL3X, may affect their antigenicity or CSA-binding affinity, eventually increasing parasitemia and its adverse effects on pregnancy outcomes. A total of 373 DBL2X and 328 DBL3X sequences were obtained from transcripts of 20 placental isolates infecting Mozambican women, resulting in 176 DBL2X and 191 DBL3X unique sequences at the protein level. Sequence alignments were divided in segments containing combinations of correlated polymorphisms and the association of segment sequences with placental parasite density was tested using Bonferroni corrected regression models, taking into consideration the weight of each sequence in the infection. Three DBL2X and three DBL3X segments contained signatures of high parasite density (P<0.003) that were highly prevalent in the parasite population (49-91%). Identified regions included a flexible loop that contributes to DBL3X-CSA interaction and two DBL3X motifs with evidence of positive natural selection. Limited antibody responses against signatures of high parasite density among malaria-exposed pregnant women could not explain the increased placental parasitemia. These results suggest that a higher binding efficiency to CSA rather than reduced antigenicity might provide a biological advantage to parasites with high parasite density signatures in VAR2CSA. Sequences contributing to high parasitemia may be critical for the functional characterization of VAR2CSA and the development of tools against placental malaria

Cost-Effectiveness of Intermittent Preventive Treatment of Malaria in Pregnancy in Southern Mozambique

BACKGROUND: Malaria in pregnancy is a public health problem for endemic countries. Economic evaluations of malaria preventive strategies in pregnancy are needed to guide health policies. METHODS AND FINDINGS: This analysis was carried out in the context of a trial of malaria intermittent preventive treatment in pregnancy with sulphadoxine-pyrimethamine (IPTp-SP), where both intervention groups received an insecticide treated net through the antenatal clinic (ANC) in Mozambique. The cost-effectiveness of IPTp-SP on maternal clinical malaria and neonatal survival was estimated. Correlation and threshold analyses were undertaken to assess the main factors affecting the economic outcomes and the cut-off values beyond which the intervention is no longer cost-effective. In 2007 US$, the incremental cost-effectiveness ratio (ICER) for maternal malaria was 41.46 US$ (95% CI 20.5, 96.7) per disability-adjusted life-year (DALY) averted. The ICER per DALY averted due to the reduction in neonatal mortality was 1.08 US$(95$ (95% CI 0.42, 3.21) per DALY averted. Efficacy was the main factor affecting the economic evaluation of IPTp-SP. The intervention remained cost-effective with an increase in drug cost per dose up to 11 times in the case of maternal malaria and 183 times in the case of neonatal mortality. CONCLUSIONS: IPTp-SP was highly cost-effective for both prevention of maternal malaria and reduction of neonatal mortality in Mozambique. These findings are likely to hold for other settings where IPTp-SP is implemented through ANC visits. The intervention remained cost-effective even with a significant increase in drug and other intervention costs. Improvements in the protective efficacy of the intervention would increase its cost-effectiveness. Provision of IPTp with a more effective, although more expensive drug than SP may still remain a cost-effective public health measure to prevent malaria in pregnancy. TRIAL REGISTRATION: ClinicalTrials.gov NCT00209781

Resonant hyper-Raman scattering in spherical quantum dots

A theoretical model of resonant hyper-Raman scattering by an ensemble of spherical semiconductor quantum dots has been developed. The electronic intermediate states are described as Wannier-Mott excitons in the framework of the envelope function approximation. The optical polar vibrational modes of the nanocrystallites (vibrons) and their interaction with the electronic system are analized with the help of a continuum model satisfying both the mechanical and electrostatic matching conditions at the interface. An explicit expression for the hyper-Raman scattering efficiency is derived, which is valid for incident two-photon energy close to the exciton resonances. The dipole selection rules for optical transitions and Fr\"ohlich-like exciton-lattice interaction are derived: It is shown that only exciton states with total angular momentum $L=0,1$ and vibrational modes with angular momentum $l_p=1$ contribute to the hyper-Raman scattering process. The associated exciton energies, wavefunctions, and vibron frequencies have been obtained for spherical CdSe zincblende-type nanocrystals, and the corresponding hyper-Raman scattering spectrum and resonance profile are calculated. Their dependence on the dot radius and the influence of the size distribution on them are also discussed.Comment: 12 pages REVTeX (two columns), 2 tables, 8 figure

The starburst-AGN connection in the merger galaxy Mrk 938: an infrared and X-ray view

Mrk938 is a luminous infrared galaxy in the local Universe believed to be the remnant of a galaxy merger. It shows a Seyfert 2 nucleus and intense star formation according to optical spectroscopic observations. We have studied this galaxy using new Herschel far-IR imaging data in addition to archival X-ray, UV, optical, near-IR and mid-IR data. Mid- and far-IR data are crucial to characterise the starburst contribution, allowing us to shed new light on its nature and to study the coexistence of AGN and starburst activity in the local Universe. The decomposition of the mid-IR Spitzer spectrum shows that the AGN bolometric contribution to the mid-IR and total infrared luminosity is small (Lbol(AGN)/LIR~0.02), which agrees with previous estimations. We have characterised the physical nature of its strong infrared emission and constrained it to a relatively compact emitting region of <2kpc. It is in this obscured region where most of the current star formation activity is taking place as expected for LIRGs. We have used Herschel imaging data for the first time to constrain the cold dust emission with unprecedented accuracy. We have fitted the integrated far-IR spectral energy distribution and derived the properties of the dust, obtaining a dust mass of 3x10^7Msun. The far-IR is dominated by emission at 35K, consistent with dust heated by the on-going star formation activity.Comment: 12 pages, 6 figures, 4 tables, accepted for publication in MNRA