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Concept: Income


The detrimental impact of smoking on health has been widely documented since the 1960s. Numerous studies have also quantified the economic cost that smoking imposes on society. However, these studies have mostly been in high income countries, with limited documentation from developing countries. The aim of this paper is to measure the economic cost of smoking-attributable diseases in countries throughout the world, including in low- and middle-income settings.

Concepts: Costs, Developing country, Generally Accepted Accounting Principles, World, Income, Economics


Human mobility is increasing in its volume, speed and reach, leading to the movement and introduction of pathogens through infected travelers. An understanding of how areas are connected, the strength of these connections and how this translates into disease spread is valuable for planning surveillance and designing control and elimination strategies. While analyses have been undertaken to identify and map connectivity in global air, shipping and migration networks, such analyses have yet to be undertaken on the road networks that carry the vast majority of travellers in low and middle income settings. Here we present methods for identifying road connectivity communities, as well as mapping bridge areas between communities and key linkage routes. We apply these to Africa, and show how many highly-connected communities straddle national borders and when integrating malaria prevalence and population data as an example, the communities change, highlighting regions most strongly connected to areas of high burden. The approaches and results presented provide a flexible tool for supporting the design of disease surveillance and control strategies through mapping areas of high connectivity that form coherent units of intervention and key link routes between communities for targeting surveillance.

Concepts: Border, Income, Disease, Graph connectivity, Road, Epidemiology, Bridge, Integral


About 57% of the total number of cancer cases occur in low and middle income countries. Radiotherapy is one of the main components of cancer treatment and requires substantial initial investment in infrastructure and training. Many departments continue to have basic facilities and to use simple techniques, while modern technologies have only been installed in big cities in upper-middle income countries. More than 50% of cancer patients requiring radiotherapy in low and middle income countries lack access to treatment. The situation is dramatic in low income countries, where the proportion is higher than 90%. The overall number of additional teletherapy units needed corresponds to about twice the installed capacity in Europe. The figures for different income level groups clearly show the correlation between gross national income per capita and the availability of services. The range of radiotherapy needs currently covered varies from 0% and 3-4% in low income countries in Latin America and Africa up to 59-79% in upper-middle income countries in Europe and Central Asia. The number of additional radiation oncologists, medical physicist, dosimetrists and radiation therapists (RTTs) required to operate additional radiotherapy departments needed is 43 200 professionals. Training and education programmes are not available in every developing country and in many cases the only option is sending trainees abroad, which is not a cost-effective solution. The implementation of adequate local training should be the following step after establishing the first radiotherapy facility in any country. Joint efforts should be made to establish at least one radiotherapy facility in countries where they do not exist, in order to create radiotherapy communities that could be the base for future expansion.

Concepts: Radiation oncology, Chemotherapy, Household income in the United States, Income, Radiation oncologist, Cancer, Oncology, Radiation therapy


The objective of this study was to quantify changes in the affordability of sugar-sweetened beverages, a product implicated as a contributor to rising rates of obesity worldwide, as a function of product price and personal income.

Concepts: Income


Ongoing deforestation is a pressing, global environmental issue with direct impacts on climate change, carbon emissions, and biodiversity. There is an intuitive link between economic development and overexploitation of natural resources including forests, but this relationship has proven difficult to establish empirically due to both inadequate data and convoluting geo-climactic factors. In this analysis, we use satellite data on forest cover along national borders in order to study the determinants of deforestation differences across countries. Controlling for trans-border geo-climactic differences, we find that income per capita is the most robust determinant of differences in cross-border forest cover. We show that the marginal effect of per capita income growth on forest cover is strongest at the earliest stages of economic development, and weakens in more advanced economies, presenting some of the strongest evidence to date for the existence of at least half of an environmental Kuznets curve for deforestation.

Concepts: Border, Climate change, Economic development, Simon Kuznets, Income, Per capita income, Economics, Sustainability


Unhygienic and ineffective menstrual hygiene management has been documented across low resource contexts and linked to negative consequences for women and girls.

Concepts: Household income in the United States, Middle class, Income


This cost-effectiveness study analyzes the cost per quality-adjusted life year (QALY) gained in a randomized controlled trial that tested school support as a structural intervention to prevent HIV risk factors among Zimbabwe orphan girl adolescents. The intervention significantly reduced early marriage, increased years of schooling completed, and increased health-related quality of life. By reducing early marriage, the literature suggests the intervention reduced HIV infection. The intervention yielded an estimated US$1,472 in societal benefits and an estimated gain of 0.36 QALYs per orphan supported. It cost an estimated US$6/QALY gained, about 1 % of annual per capita income in Zimbabwe. That is well below the maximum price that the World Health Organization (WHO) Commission on Macroeconomics and Health recommends paying for health gains in low and middle income countries. About half the girls in the intervention condition were boarded when they reached high school. For non-boarders, the intervention’s financial benefits exceeded its costs, yielding an estimated net cost savings of $502 per pupil. Without boarding, the intervention would yield net savings even if it were 34 % less effective in replication. Boarding was not cost-effective. It cost an additional $1,234 per girl boarded (over the 3 years of the study, discounted to present value at a 3 % discount rate) but had no effect on any of the outcome measures relative to girls in the treatment group who did not board. For girls who did not board, the average cost of approximately 3 years of school support was US$973.

Concepts: World Health Organization, Per capita income, Income, Gain, High school, Cost-utility analysis, Health economics, Costs


In order to gather a global picture of vaccine hesitancy and whether/how it is changing, an analysis was undertaken to review three years of data available as of June 2017 from the WHO/UNICEF Joint Report Form (JRF) to determine the reported rate of vaccine hesitancy across the globe, the cited reasons for hesitancy, if these varied by country income level and/or by WHO region and whether these reasons were based upon an assessment. The reported reasons were classified using the Strategic Advisory Group of Experts (SAGE) on Immunization matrix of hesitancy determinants ( Hesitancy was common, reported by >90% of countries. The list of cited reasons was long and covered 22 of 23 WHO determinants matrix categories. Even the most frequently cited category, risk- benefit (scientific evidence e.g. vaccine safety concerns), accounted for less than one quarter of all reasons cited. The reasons varied by country income level, by WHO region and over time and within a country. Thus based upon this JRF data, across the globe countries appear to understand the SAGE vaccine hesitancy definition and use it to report reasons for hesitancy. However, the rigour of the cited reasons could be improved as only just over 1/3 of countries reported that their reasons were assessment based, the rest were opinion based. With respect to any assessment in the previous five years, upper middle income countries were the least likely to have done an assessment. These analyses provided some of the evidence for the 2017 Assessment Report of the Global Vaccine Action Plan recommendation that each country develop a strategy to increase acceptance and demand for vaccination, which should include ongoing community engagement and trust-building, active hesitancy prevention, regular national assessment of vaccine concerns, and crisis response planning (

Concepts: The Sage Gateshead, Country, Income, Upper middle class, Immune system, Report, Household income in the United States, Vaccination


CONTEXT:: Major funding cuts have occurred throughout the United States public health system during the past several years. Funding for local public health agency (LPHA) services and programs is obtained through a patchwork of sources that vary both within and among states. Even though local city and county sources provide a significant proportion of funding for LPHAs, information available in the literature about these revenues is sparse and is not clearly described. OBJECTIVE:: This study focused on a single specific revenue stream included in the local sources (local city and county) category: funds voted on directly by the public. The primary purpose of this study was to examine whether this type of funding source provided fiscal advantages for LPHAs. Specifically, we wanted to see how sensitive levy votes were to changing general economic conditions. METHODS:: A questionnaire to collect LPHA levy data was developed, approved, and mailed to county boards of elections in Ohio (n = 88). Elections officials were asked to provide voting results for all LPHA levy ballot attempts since 1994 regardless of outcome. RESULTS:: In the study period (1994 through 2011), 250 LPHA property tax levies were placed on election ballots in Ohio. LPHAs were successful in 155 (62.0%) and unsuccessful in 95 (38.0%) attempts. Over the 18-year period, the most noteworthy outcome was a 94.6% pass rate for renewal levies. CONCLUSION:: Our study demonstrated that voter-approved tax levies provide some fiscal advantages for LPHAs: higher per capita revenues than those who have to rely on other sources of income and predictable revenue streams. This translates into more funds being available for public health programs and services. Property tax levies allow citizens to make direct investments in their local health departments.

Concepts: Health, Universal health care, Voting system, Health economics, Voting, Income, Tax, Public health


Since its initial discovery in anEscherichia coliisolate from China,mcr-1has also been detected inKlebsiella pneumoniaeandSalmonella enterica, and is rarely reported in other Enterobacteriaceae. Here, we report the isolation and identification of aShigella flexneristrain harboringmcr-1from stool samples in a pig farm in China from 2009. The minimum inhibitory concentration (MIC) to colistin of the isolate is 4 μg/mL. Conjugation assays showed the donorS. flexneristrain has functional and transferable colistin resistance. Sequencing revealed thatmcr-1was present on a putative composite transposon flanked by inverted repeats of ISApl1ImportanceThere are four species ofShigella,Shigella flexneriis the most frequently isolated species in Low and Middle Income Countries (LMICs). In this study, we report a functional, transferable, plasmid mediatedmcr-1inS.flexneriWe have shownmcr-1is located on a novel composite transposon which is flanked by inverted repeats of ISApl1The host strain is multi-drug resistant and this multidrug resistance is also transferable. The finding of functionalmcr-1inS. flexneri; a human associated Enterobacteriaceae is a cause for concern as infections due toS. flexneriare the mainShigellainfections in most Low and Middle Income Countries.

Concepts: Household income in the United States, Report, Middle class, Income, Escherichia coli, Antibiotic resistance, Plasmid, Molecular biology