Some more information on the question of teaching clinical epidemiology in medical schools

The article presents the definition, purpose and objectives of clinical epidemiology. It describes the different aspects of clinical epidemiology (theoretical, methodological and practical) that should be included in the educational programs. The purposes of medical higher education institutes include the formation of competences on evaluation of the diagnostic and healing process effectiveness in clinical practice as well as the effectiveness of preventive and anti-epidemic measures. Nowadays it is necessary to prepare qualified specialists with relevant professional knowledge, skills and decision-maker abilities in order to use the methods of disease treatment and prevention according to the evidence-based medicine standards. Many leading medical educational organisations have introduced Сlinical Epidemiology in the compulsory course as one of the fundamental disciplines. Modern educational programs on the discipline of Epidemiology require the expansion of the teaching of Clinical Epidemiology both in the basic educational programs and in the selected disciplines

О НЕОБХОДИМОСТИ СОВЕРШЕНСТВОВАНИЯ ТАКТИКИ ИММУНОПРОФИЛАКТИКИ КОКЛЮША

The aim of the study was to identify current epidemiological patterns of pertussis and to assess the need to improve immunization against this infection. Methods. A comparative retrospective epidemiological analysis of pertussis incidence in Russian population, in several European countries and in certain social and age groups has been performed considering vaccination coverage, immunization strategy, and diagnostic tests. A comparative analysis of gen eral and agerelated morbidity of and mortality from infectious and respiratory diseases in Russian population and in some European countries has also been performed. Data on morbidity, mortality and vaccination were obtained from databases of WHO and the Federal State Statistic Service of Russian Federation. Results. The epidemiological situation evolving pertussis is not good in Russia. The morbidity growth including high morbidity in infants and growing morbidity in children of 7–14 years old reflects active pathogen circulation in population. There is higher mortality from infectious and respiratory diseases in general population and in infants in Russia compared to European countries. Conclusion. The current approach to epidemiological surveillance on pertussis in Russia needs to be improved. Implementation of molecular and other new laboratory methods for pertussis diagnosis could improve identi fication of the infection sources, etiological diagnosis and treatment efficacy. The morbidity of pertussis could be decreased by a wide use of acellular vac cine and additional revaccinations. Цель. Выявление эпидемиологических закономерностей коклюша на современном этапе для оценки необходимости совершенствования тактики иммунопрофилактики. Материалы и методы. Для выявления эпидемиологических особенностей проведен сравнительный ретроспективный эпидемиологический анализ заболеваемости коклюшем населения России и отдельных социально-возрастных групп, а также сравнительный анализ заболеваемости коклюшем по отдельным европейским странам в зависимости от охвата прививками против коклюша, тактики иммунопрофилактики коклюша и используемых диагностических тестов. Для оценки уровня организации иммунопрофилактической работы проведен сравнительный анализ общих и возрастных показателей заболеваемости и смертности от инфекционных и респираторных заболеваний населения России и отдельных европейских стран. Выборка данных о заболеваемости, смертности и тактике вакцинации проводилась на основании баз данных заболеваемости и смертности Европейского бюро Всемирной организации здравоохранения и Федеральной службы государственной статистики (Росстат); Формы № 2 «Сведения об инфекционных и паразитарных заболеваниях» и Формы № 6 «Сведения о контингентах детей и взрослых, привитых против инфекционных заболеваний». Результаты. Эпидемическую ситуацию по коклюшу в России в настоящее время нельзя считать благополучной. Рост общей заболеваемости, высокие показатели заболеваемости детей до 1 года, увеличение заболеваемости детей в возрасте 7–14 лет свидетельствуют об активной циркуляции коклюшного микроба в популяции. Неблагополучие ситуации подтверждено более высокими по сравнению с европейскими странами показателями смертности от инфекционных и респираторных болезней как в масштабе населения в целом, так и детей до 1 года. Заключение. В организации диагностики и иммунопрофилактики коклюшной инфекции Россия отстает от развитых стран примерно на 10 лет, в связи с чем назрела очевидная необходимость совершенствования существующей системы эпидемиологического надзора за данным заболеванием. Совершенствование молекулярно-генетических и других методов лабораторной диагностики коклюша позволит в значительной степени улучшить выявление источников и этиологическую расшифровку данной инфекции, повысить эффективность этиотропного лечения. Изменение тактики иммунопрофилактики коклюшной инфекции путем широкого внедрения ацеллюлярной вакцины и введения дополнительных возрастных ревакцинаций в Национальный календарь профилактических прививок будет способствовать снижению показателей заболеваемости и улучшению состояния общественного здоровья

ВАКЦИНАЦИЯ ВЗРОСЛЫХ ПРОТИВ ПНЕВМОКОККОВОЙ ИНФЕКЦИИ В РОССИЙСКОЙ ФЕДЕРАЦИИ: СОЦИАЛЬНЫЕ И ФАРМАКОЭКОНОМИЧЕСКИЕ АСПЕКТЫ

Vaccination against pneumococcal infections by 13-valent conjugate vaccine (PCV13) can significantly reduce morbidity and mortality.The study has been aimed to evaluate the social and pharmacoeconomic aspects of PCV13 vaccination of 65-year-old patients with various risks of pneumococcal infection.Material and methods. Markov model with 5 and 15 years time horizon was used for the analysis from the position of the health care system.The analysis was carried out for 65-year-old citizens with low (absence of immunocompromized conditions and chronic diseases), moderate (patients with chronic diseases without immunodeficiency) and high (immunocompromized conditions) risk of pneumococcal infection as well as for the entire population of 65-year-old citizens, regardless of the risk level.In base-case assumption has been made that 1 dose of PCV13 should be administered for the patients from low and moderate risk groups and in the high-risk group 1 dose of PCV13 and in 8 weeks a dose of polysaccharide pneumococcal vaccine (PPV23) should be given.The treatment and physician visit costs have been calculated using CHI rates for St. Petersburg in 2018. Vaccination cost was calculated using the auction price to purchase PCV13 and PPV23 in 2018.Results. Vaccination of 1 cohort of 65-year-old citizens in Russian Federation within 5 years will result in prevention of 2200 deaths, 3900 cases of invasive pneumococcal diseases (IPD) and 48700 cases of community-acquired pneumonia. In 15 years prevention of about 4,3 thousand deaths, 6,6 thousand IPD and 101,1 thousand cases of CAP will be provided.Within 15-year horizon the cost-effectiveness ratio will be RUR 30,3, 82,4 and 410,0 thousand per QALY in high, moderate and low risk groups, respectively. Even if the time horizon is reduced to 5 years the PCV13 vaccination can be considered as an economically high-efficient intervention in moderate and high risk groups (cost-effectiveness ratio - RUR 279,2 and 221,7 thousand / QALY, respectively).In the 15-year-horizon noting the distribution of 65-yearolds by risk levels the cost-effectiveness ratio of PCV13 in population as a whole will be RUR 216,4 thousand / QALY. If moderate and high risk groups only are vaccinated, the average cost-effectiveness ratio will drop to RUR 67,6 thousand /QALY. At universal PCV13 vaccination of 65 years old in 5 year time horizon return of investment to the health care system budget will be 33.2% and at vaccination of persons with moderate and high risk return of investment will be 44.0%. With the assumption of vaccination during the planned physician visit (without additional visit) the return to the budget will be 46.8% and 60.9% for vaccination of all 65-year-olds and patients from the moderate and high risk groups, respectively.Conclusions. Vaccination of the 65-year-old persons against PCV13 pneumococcal infection in Russian Federation can be considered as a highly socially and economically effective intervention resulting in significant reduction of pneumococcal infection incidence and related mortality. The cost-effectiveness of vaccination is increasing along with the level of the risk. PCV13 vaccination of patients with moderate and high risk only provides a significant reduction in the burden for the health care budget in comparison with the vaccination of the entire population of 65-year-olds.Вакцинация против пневмококковых инфекций 13-валентной конъюгированной вакциной (ПКВ13) позволяет существенно снизить соответствующую заболеваемость и летальность.Цель: оценка социальных и фармакоэкономических аспектов вакцинации ПКВ13 65-летних пациентов с различным уровнем риска пневмококковой инфекции.Материалы и методы. Анализ осуществляли методом марковского моделирования с позиции системы здравоохранения. Временной горизонт – 5 и 15 лет.Анализ проводили для 65-летних граждан с низким (пациенты без нарушений иммунитета и хронических заболеваний), умеренным (пациенты без нарушений иммунитета с наличием хронических заболеваний) и высоким (пациенты с нарушениями иммунитета) риском развития пневмококковых инфекций, а также для всей популяции 65-летних граждан, независимо от уровня риска.В базовом варианте предполагали, что в группах низкого и умеренного риска осуществляется вакцинация 1 дозой ПКВ13, а в группе высокого риска – 1 дозой ПКВ13 и 1 дозой полисахаридной пневмококковой вакцины (ППВ23) через 8 недель. Затраты на терапию пневмококковых инфекций рассчитывались на основе тарифов ОМС по СанктПетербургу на 2018 г.Затраты на вакцинацию рассчитывались на основе цены аукционов по закупке ПКВ13 и ППВ23 за 2018 г. и затрат на визит к терапевту в соответствии с тарифом ОМС.Результаты. При вакцинации 1 когорты 65-летних граждан в РФ за 5 лет будут предотвращены около 2,2 тыс. летальных исходов, 3,9 тыс. случаев инвазивной пневмококковой инфекции (ИПИ) и 48,7 тыс. случаев заболевания внебольничной пневмонией. За 15 лет количество предотвращенных летальных исходов составит около 4,3 тыс., предотвращенных случаев ИПИ – 6,6 тыс., а предотвращенных случаев заболевания внебольничной пневмонией – 101,1 тыс.Коэффициент эффективности затрат составляет при 15-летнем горизонте 30,3, 82,4 и 410,0 тыс. руб. в расчете на дополнительный год жизни с учетом качества QALY в группах высокого, умеренного и низкого риска соответственно. Даже при снижении временного горизонта до 5 лет, в группах умеренного и высокого риска вакцинация ПКВ13 может рассматриваться как экономически высокоэффективное вмешательство (коэффициент эффективности затрат – 279,2 и 221,7 тыс. руб./QALY соответственно).С учетом распределения 65-летних граждан по уровням риска, при 15-летнем горизонте средняя эффективность затрат на вакцинацию ПКВ13 в популяции в целом составит 216,4 тыс. руб./QALY. Если осуществлять вакцинацию только граждан из групп умеренного и высокого риска, средний коэффициент «затраты/эффективность» снизится до 67,6 тыс. руб./QALY.При вакцинации всех 65-летних граждан за 5 лет в бюджет системы здравоохранения вернется 33,2%, при вакцинации только пациентов из групп высокого и умеренного риска – 44,0%. При допущении о вакцинации в ходе планового визита к врачу (без дополнительного визита) доля средств, которые вернутся в бюджет системы здравоохранения, составит 46,8% и 60,9% при вакцинации всех 65-летних граждан и пациентов из групп умеренного и высокого риска соответственно.Выводы. Вакцинация граждан РФ в возрасте 65 лет против пневмококковой инфекции ПКВ13 может рассматриваться в качестве социально и экономически высокоэффективного вмешательства, обеспечивающего существенное снижение заболеваемости пневмококковыми инфекциями и обусловленной ею летальности. Экономическая эффективность вакцинации возрастает с увеличением риска развития пневмококковых инфекций в вакцинируемой группе. Вакцинация ПКВ13 только пациентов из групп умеренного и высокого риска обеспечивает существенное снижение нагрузки на бюджет по сравнению с вакцинацией всей популяции 65-летних граждан.

Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990–2019, for 204 countries and territories: the Global Burden of Diseases Study 2019

Background: The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic. Methods: To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0·03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1·0). Findings: In 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1–38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78–0·91) per female living with HIV in 2019, 0·99 male infections (0·91–1·10) for every female infection, and 1·02 male deaths (0·95–1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58–35·43, and a 39·66% decrease in deaths, 36·49–42·36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0·05 (95% UI 0·05–0·06) and the global incidence-to-mortality ratio was 1·94 (1·76–2·12). No regions met suggested thresholds for progress. Interpretation: Sub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics. Funding: The Bill & Melinda Gates Foundation, the National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH

Diabetes mortality and trends before 25 years of age: an analysis of the Global Burden of Disease Study 2019

Background Diabetes, particularly type 1 diabetes, at younger ages can be a largely preventable cause of death with the correct health care and services. We aimed to evaluate diabetes mortality and trends at ages younger than 25 years globally using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. Methods We used estimates of GBD 2019 to calculate international diabetes mortality at ages younger than 25 years in 1990 and 2019. Data sources for causes of death were obtained from vital registration systems, verbal autopsies, and other surveillance systems for 1990–2019. We estimated death rates for each location using the GBD Cause of Death Ensemble model. We analysed the association of age-standardised death rates per 100 000 population with the Socio-demographic Index (SDI) and a measure of universal health coverage (UHC) and described the variability within SDI quintiles. We present estimates with their 95% uncertainty intervals. Findings In 2019, 16 300 (95% uncertainty interval 14 200 to 18 900) global deaths due to diabetes (type 1 and 2 combined) occurred in people younger than 25 years and 73·7% (68·3 to 77·4) were classified as due to type 1 diabetes. The age-standardised death rate was 0·50 (0·44 to 0·58) per 100 000 population, and 15 900 (97·5%) of these deaths occurred in low to high-middle SDI countries. The rate was 0·13 (0·12 to 0·14) per 100 000 population in the high SDI quintile, 0·60 (0·51 to 0·70) per 100 000 population in the low-middle SDI quintile, and 0·71 (0·60 to 0·86) per 100 000 population in the low SDI quintile. Within SDI quintiles, we observed large variability in rates across countries, in part explained by the extent of UHC (r2=0·62). From 1990 to 2019, age-standardised death rates decreased globally by 17·0% (−28·4 to −2·9) for all diabetes, and by 21·0% (–33·0 to −5·9) when considering only type 1 diabetes. However, the low SDI quintile had the lowest decline for both all diabetes (−13·6% [–28·4 to 3·4]) and for type 1 diabetes (−13·6% [–29·3 to 8·9]). Interpretation Decreasing diabetes mortality at ages younger than 25 years remains an important challenge, especially in low and low-middle SDI countries. Inadequate diagnosis and treatment of diabetes is likely to be major contributor to these early deaths, highlighting the urgent need to provide better access to insulin and basic diabetes education and care. This mortality metric, derived from readily available and frequently updated GBD data, can help to monitor preventable diabetes-related deaths over time globally, aligned with the UN's Sustainable Development Targets, and serve as an indicator of the adequacy of basic diabetes care for type 1 and type 2 diabetes across nations.publishedVersio

Estimating global injuries morbidity and mortality: methods and data used in the Global Burden of Disease 2017 study

BACKGROUND: While there is a long history of measuring death and disability from injuries, modern research methods must account for the wide spectrum of disability that can occur in an injury, and must provide estimates with sufficient demographic, geographical and temporal detail to be useful for policy makers. The Global Burden of Disease (GBD) 2017 study used methods to provide highly detailed estimates of global injury burden that meet these criteria. METHODS: In this study, we report and discuss the methods used in GBD 2017 for injury morbidity and mortality burden estimation. In summary, these methods included estimating cause-specific mortality for every cause of injury, and then estimating incidence for every cause of injury. Non-fatal disability for each cause is then calculated based on the probabilities of suffering from different types of bodily injury experienced. RESULTS: GBD 2017 produced morbidity and mortality estimates for 38 causes of injury. Estimates were produced in terms of incidence, prevalence, years lived with disability, cause-specific mortality, years of life lost and disability-adjusted life-years for a 28-year period for 22 age groups, 195 countries and both sexes. CONCLUSIONS: GBD 2017 demonstrated a complex and sophisticated series of analytical steps using the largest known database of morbidity and mortality data on injuries. GBD 2017 results should be used to help inform injury prevention policy making and resource allocation. We also identify important avenues for improving injury burden estimation in the future

Measuring routine childhood vaccination coverage in 204 countries and territories, 1980-2019: a systematic analysis for the Global Burden of Disease Study 2020, Release 1

Background: Measuring routine childhood vaccination is crucial to inform global vaccine policies and programme implementation, and to track progress towards targets set by the Global Vaccine Action Plan (GVAP) and Immunization Agenda 2030. Robust estimates of routine vaccine coverage are needed to identify past successes and persistent vulnerabilities. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020, Release 1, we did a systematic analysis of global, regional, and national vaccine coverage trends using a statistical framework, by vaccine and over time. // Methods: For this analysis we collated 55 326 country-specific, cohort-specific, year-specific, vaccine-specific, and dose-specific observations of routine childhood vaccination coverage between 1980 and 2019. Using spatiotemporal Gaussian process regression, we produced location-specific and year-specific estimates of 11 routine childhood vaccine coverage indicators for 204 countries and territories from 1980 to 2019, adjusting for biases in country-reported data and reflecting reported stockouts and supply disruptions. We analysed global and regional trends in coverage and numbers of zero-dose children (defined as those who never received a diphtheria-tetanus-pertussis [DTP] vaccine dose), progress towards GVAP targets, and the relationship between vaccine coverage and sociodemographic development. // Findings: By 2019, global coverage of third-dose DTP (DTP3; 81·6% [95% uncertainty interval 80·4–82·7]) more than doubled from levels estimated in 1980 (39·9% [37·5–42·1]), as did global coverage of the first-dose measles-containing vaccine (MCV1; from 38·5% [35·4–41·3] in 1980 to 83·6% [82·3–84·8] in 2019). Third-dose polio vaccine (Pol3) coverage also increased, from 42·6% (41·4–44·1) in 1980 to 79·8% (78·4–81·1) in 2019, and global coverage of newer vaccines increased rapidly between 2000 and 2019. The global number of zero-dose children fell by nearly 75% between 1980 and 2019, from 56·8 million (52·6–60·9) to 14·5 million (13·4–15·9). However, over the past decade, global vaccine coverage broadly plateaued; 94 countries and territories recorded decreasing DTP3 coverage since 2010. Only 11 countries and territories were estimated to have reached the national GVAP target of at least 90% coverage for all assessed vaccines in 2019. // Interpretation: After achieving large gains in childhood vaccine coverage worldwide, in much of the world this progress was stalled or reversed from 2010 to 2019. These findings underscore the importance of revisiting routine immunisation strategies and programmatic approaches, recentring service delivery around equity and underserved populations. Strengthening vaccine data and monitoring systems is crucial to these pursuits, now and through to 2030, to ensure that all children have access to, and can benefit from, lifesaving vaccines

Five insights from the Global Burden of Disease Study 2019

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a rules-based synthesis of the available evidence on levels and trends in health outcomes, a diverse set of risk factors, and health system responses. GBD 2019 covered 204 countries and territories, as well as first administrative level disaggregations for 22 countries, from 1990 to 2019. Because GBD is highly standardised and comprehensive, spanning both fatal and non-fatal outcomes, and uses a mutually exclusive and collectively exhaustive list of hierarchical disease and injury causes, the study provides a powerful basis for detailed and broad insights on global health trends and emerging challenges. GBD 2019 incorporates data from 281 586 sources and provides more than 3.5 billion estimates of health outcome and health system measures of interest for global, national, and subnational policy dialogue. All GBD estimates are publicly available and adhere to the Guidelines on Accurate and Transparent Health Estimate Reporting. From this vast amount of information, five key insights that are important for health, social, and economic development strategies have been distilled. These insights are subject to the many limitations outlined in each of the component GBD capstone papers.Peer reviewe