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The World Health Organization (WHO) recommends oral cholera vaccines (OCVs) as a supplementary tool to conventional prevention of cholera. Dukoral, a killed whole-cell two-dose OCV, was used in a mass vaccination campaign in 2009 in Zanzibar. Public and private costs of illness (COI) due to endemic cholera and costs of the mass vaccination campaign were estimated to assess the cost-effectiveness of OCV for this particular campaign from both the health care provider and the societal perspective.
Methodology/Principal Findings
Public and private COI were obtained from interviews with local experts, with patients from three outbreaks and from reports and record review. Cost data for the vaccination campaign were collected based on actual expenditure and planned budget data. A static cohort of 50,000 individuals was examined, including herd protection. Primary outcome measures were incremental cost-effectiveness ratios (ICER) per death, per case and per disability-adjusted life-year (DALY) averted. One-way sensitivity and threshold analyses were conducted. The ICER was evaluated with regard to WHO criteria for cost-effectiveness. Base-case ICERs were USD 750,000 per death averted, USD 6,000 per case averted and USD 30,000 per DALY averted, without differences between the health care provider and the societal perspective. Threshold analyses using Shanchol and assuming high incidence and case-fatality rate indicated that the purchase price per course would have to be as low as USD 1.2 to render the mass vaccination campaign cost-effective from a health care provider perspective (societal perspective: USD 1.3).
Based on empirical and site-specific cost and effectiveness data from Zanzibar, the 2009 mass vaccination campaign was cost-ineffective mainly due to the relatively high OCV purchase price and a relatively low incidence. However, mass vaccination campaigns in Zanzibar to control endemic cholera may meet criteria for cost-effectiveness under certain circumstances, especially in high-incidence areas and at OCV prices below USD 1.3.
Author Summary
Despite efforts to improve water supply and sanitation, cholera still represents a serious burden in developing countries. Use of oral cholera vaccines (OCVs) in endemic and epidemic situations has recently shown a promising potential to mitigate this burden. To provide local decision-makers with specific information on OCV use for cholera control, we assessed the costs and benefits of a mass vaccination campaign that was conducted in 2009 in selected endemic areas of Zanzibar. We estimated the cost-effectiveness of OCVs by collecting health care provider and household costs of illness from cholera outbreaks and costs of the mass vaccination campaign that used the two-dose OCV Dukoral. Cost-effectiveness was expressed as the incremental costs of the one-off vaccination program per case, per death and per disability-adjusted life-year averted, over a three-year time period. Our model showed that the 2009 mass vaccination campaign in Zanzibar was not cost-effective, mainly due to the high OCV price (USD 10) and the relatively low incidence. Threshold analyses with Shanchol, the second OCV that is recommended by the WHO, indicated that mass vaccination in Zanzibar to control endemic cholera may become cost-effective if done in higher incidence areas and when OCV prices are reduced to levels below USD 1.3.
Citation: Schaetti C, Weiss MG, Ali SM, Chaignat C-L, Khatib AM, Reyburn R, et al. (2012) Costs of Illness Due to Cholera, Costs of Immunization and Cost-Effectiveness of an Oral Cholera Mass Vaccination Campaign in Zanzibar. PLoS Negl Trop Dis 6(10): e1844. https://doi.org/10.1371/journal.pntd.0001844
Editor: Edward T. Ryan, Massachusetts General Hospital, United States of America
Received: February 15, 2012; Accepted: August 20, 2012; Published: October 4, 2012
Copyright: © Schaetti et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The authors acknowledge funding of this study from the Bill & Melinda Gates Foundation, Seattle, United States of America (http://www.gatesfoundation.org). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Despite efforts to improve water supply and sanitation, cholera still represents a serious public health burden in low- and middle-income countries. In 2009, more than 220,000 cases and almost 5,000 deaths were reported to the World Health Organization (WHO) [1]. Due to underreporting and difficulties with surveillance, however, the true burden is likely in the range of 3 million cases and 100,000 deaths per year [2], [3]. A recent review of official cholera-related morbidity and mortality data from the WHO Africa region also indicated a potential economic burden of cholera for families and the health sector [4].
Cholera is an enteric bacterial disease caused by Vibrio cholerae serogroup O1 or O139 that usually occurs in sudden epidemics. Main features include acute, profuse watery diarrhea and vomiting that may lead to dehydration with concurrent electrolyte loss and eventually death if timely treatment is unavailable. Even though case-fatality rates (CFRs) may reach 50%, a rate below 1% has been achieved with proper case management [3], [5]. Treatment is based on prompt rehydration with oral rehydration solution (ORS) for mild to moderate cases and intravenous (IV) fluids for severe cases [3]. Antibiotics are recommended for severe, and also moderate cases, to reduce the duration of episodes and shedding of infectious V. cholerae [3], [6].
Traditionally, cholera control has been based on prevention (i.e., adequate water supply, improved sanitation and health education, and timely treatment). The role of vaccination for cholera control has recently received increased attention from public health officials; the WHO recommends oral cholera vaccines (OCVs) as a supplementary public health tool to traditional prevention and treatment in endemic and epidemic settings [7].
A series of research studies, done as part of the Diseases of the Most Impoverished (DOMI) project coordinated by the International Vaccine Institute (IVI), evaluated the use of OCVs in Asia and Africa for control of endemic cholera. Private demand for cholera vaccines was examined through willingness-to-pay studies [8]–[11], costs of illness (COI) and mass vaccination data were collected [12]–[14], and cost-effectiveness and cost-benefit analyses were performed [15], [16]. Besides the recent article by Poulos et al. [13], published information about COI due to cholera is lacking even though patient-level data is needed for economic evaluations to improve local planning of cholera control.
A joint initiative between the WHO, the IVI and the Ministry of Health of Zanzibar (MoH) implemented a mass vaccination campaign with an OCV in two selected cholera-endemic areas of Zanzibar in 2009. This intervention-cum-research project provided the opportunity to assess costs of immunization in an endemic setting. Public COI—defined as fixed and variable costs borne by the health care provider for setting up and running cholera treatment centers (CTCs)—were estimated from three outbreaks that happened in 2009 outside the mass vaccination target communities. Private direct COI—defined as medical and non-medical expenses related to patient treatment, and indirect COI—defined as loss of income borne by patients and their families—were elicited from a sample of patients admitted to CTCs during these outbreaks.
This study aims to estimate (i) public and private COI due to cholera, (ii) costs of an oral cholera mass vaccination campaign, and (iii) the cost-effectiveness of using OCVs in endemic regions of Zanzibar from a health care provider and a societal perspective.
Ethics Statement
Written informed consent was obtained from all study participants interviewed for private costs of illness. Patients aged 18 years or older were directly interviewed while caregivers were interviewed if the patient was younger than 18 years. No incentives were provided to them. The protocol of this study was cleared by the WHO Research Ethics Review Committee and the MoH Ethics Committee. All data were handled confidentially and made anonymous before analysis.
Study Setting
Zanzibar consists of two major islands, Unguja (also named Zanzibar) and Pemba, which are situated in the Indian Ocean about 40–60 km off the coast of Tanzania. Zanzibar, a semiautonomous polity within the United Republic of Tanzania, consists of five regions, which are subdivided into ten districts, 50 constituencies and 296 Shehias, the latter being the smallest administrative unit. The main islands cover ∼2,557 km2 (Unguja: ∼1,651 km2, Pemba ∼906 km2). The archipelago is inhabited by a fast-growing population of ∼1.2 million Kiswahili-speaking Muslim people. Monthly mean per capita expenditure for all goods and services was TZS 21,000 (∼USD 18) in 2004/5 with a 2.1% share for health-related expenditures [17]. Life expectancy at birth has risen from 47 years in 1988 to 57 years in 2002 [18]. The economy of the islands depends on agriculture (primarily cloves, coconuts/copra and seaweed), fishing and tourism.
The public health care delivery structure in Zanzibar comprises two zones, Unguja and Pemba, each with three levels: the primary, the secondary and the tertiary level. Each zone is headed by a zonal medical officer. Most of the health care services are provided at the primary level through Primary Health Care Units (PHCU) (n = 124). The majority of these units is open during the day to outpatients and provides basic services. Primary Health Care Centers (PHCC) (n = 4) are additional facilities on the primary level; they operate on a 24-hours basis and can admit up to 30 patients. At the secondary level, three district hospitals (only in Pemba) are operational while the country's only tertiary level hospital (Mnazi Mmoja) is located in the capital Stonetown in Unguja. The top causes of primary- and secondary-level outpatient visits in 2008 were upper respiratory tract infections (23%), pneumonia (10%), malaria (10%) and diarrhea (9%) [19].
In recent times, the first cholera outbreak with 411 cases and 51 deaths was reported in 1978 from two fishermen villages in Zanzibar [20]. More than a dozen outbreaks followed since then with almost annual episodes since the year 2000. Reyburn et al. reported an annual incidence of 0.5 cases per 1,000 population based on a review of routine surveillance data for the years 1997 to 2007 [21], although the true incidence was likely higher due to underreporting. A seasonal pattern can be observed that follows the rainy seasons (usually from March to June and from October to December) during which widespread flooding occurs. Such deteriorating environmental conditions subsequently expose the majority of inhabitants on both islands to an increased risk of waterborne diseases due to the scarcity of safe drinking water supplies and a generally poor or lacking sanitation infrastructure in periurban and rural areas.
Based on a consideration of areas of recent cholera activity, three Shehias per island, adjacent to each other, were selected as sites for the mass vaccination campaign. In Unguja, the Shehias of Chumbuni and Karakana in Urban district and Mtopepo in West district were targeted for the campaign; in Pemba, the Shehias of Kengeja, Mwambe and Shamiani, all located in the rural southeastern Mkoani district, were chosen.
Dukoral, the only OCV that was pre-qualified by the WHO in 2009, was used in the mass vaccination campaign. Dukoral is a V. cholerae serogroup O1 whole-cell, killed vaccine containing recombinant cholera toxin (CT) B subunit protein; it has to be administered in two doses at least one week apart and requires a cold chain (2–8°C) [22]. This OCV was originally designed for immunologically naïve travelers from the north to tropical countries; it is licensed for use from two years of age and above and was shown to be 60–90% protective for up to three years [23]–[25]. One three-ml vial of Dukoral contains 1×1011 killed V. cholerae O1 (biotype classical and El Tor) and 1 mg of the CT B subunit protein in a suspension. Because the CT B subunit protein is not gastric acid-fast, the suspension has to be mixed with 1.5 dl of drinking water and a buffer sachet containing effervescent granules of sodium bicarbonate before ingestion. Recipients need to fast one hour before and after ingestion.
Cost Data Collection
Table 1 describes cost components and sources of data collected for this study. Estimates for public COI were obtained from interviews with local experts and unvaccinated patients and from reports and record review. Cost data for the mass vaccination campaign were collected based on actual expenditure and planned budget data. Private direct and indirect costs were collected through interviews done with unvaccinated patients on Pemba. All costs are reported in 2009 USD from an economic perspective, based on mid-2009 exchange rates obtained from http://www.oanda.com/currency/converter/.
Public COI.
Usually, CTCs are set up in Zanzibar once a cholera outbreak has been declared. Any identified person with acute watery diarrhea will be admitted and treated with IV fluids (Ringer's lactate, Hartmann's solution) and/or ORS, antibiotics and other drugs (Zinc for children) depending on the dehydration level. Community help-seeking behavior for cholera in peri-urban and rural Zanzibar also favors professional treatment in public health care facilities [26]. Thus, assuming that the majority of cases that occur during outbreaks are treated in CTCs, this study collected treatment costs incurred at CTCs to estimate public COI.
Public COI data from three outbreaks (one from Unguja and two from Pemba) that happened after the mass vaccination campaign were collected prospectively and retrospectively from local health care personnel and experts. All three centers were visited for an overview of how they were set up and being run. Fixed COI related to set up and running of centers, but considered independent of the number of cholera cases, included permanent material, consumables, transportation and personnel. The latter included extra (i.e., top up) payments for personnel and opportunity costs based on functions and salaries of personnel diverted from other health services. Variable COI incurred for cholera cases included drugs (resource use obtained from patient interviews) and material used for patient treatment. Current unit costs for drugs and material were provided by the chief pharmacist and the medical store department.
In Unguja, a CTC was opened on September 22, 2009, in PHCU Chumbuni after a cholera outbreak had been declared in one of the districts where the mass vaccination was conducted. A total of 161 patients were admitted over the course of 63 days before the CTC was closed on November, 29, 2009. Patients were treated in military tents (at the beginning of the outbreak) and in premises belonging to the PHCU. During the period while the CTC was operational, only suspected cholera cases were treated; patients with other illnesses were sent to adjacent clinics.
The first outbreak on Pemba occurred in Wete district, which is located between Micheweni district in the north and the Pemban capital Chake-Chake in the center of the island; the PHCU in Kiuyu Minungwini was turned into a CTC during 88 days from May 11, 2009, until August 7, 2009, when 88 patients were admitted and treated. The second outbreak on Pemba happened in Micheweni district in the northeast of the island. A school adjacent to PHCC Micheweni was turned into a CTC with male and female and pediatric wards. This center was first open from June 18, 2009, until August 11, 2009, to admit 349 patients over the course of 54 days. After another surge in cholera cases, the center was reopened on August 30, 2009, and run for an additional 31 days to treat another 32 patients until it was closed on September 30, 2009.
Private COI.
Private COI data were collected with questionnaires from laboratory-confirmed cholera patients who had not received cholera vaccines before. A convenience sample of ∼100 respondents was selected based on a list of positive cases from outbreaks kept at the Public Health Laboratory (PHL) in Chake-Chake, Pemba. Health care providers were then contacted at the CTC where the patients had been admitted to confirm details and to contact the patient or the caregiver for an interview.
Based on WHO guidelines [27], a questionnaire was constructed in an adult and a child version to elicit out-of-pocket costs for cholera cases borne by patients and affected households. After pre-testing, the questionnaire was administered in face-to-face interviews to inquire about direct medical and non-medical costs and indirect costs (i.e., productivity losses to the patient or caregiver and other household members). Patients aged 18 years or older were directly interviewed while caregivers were interviewed if the patient was younger than 18 years. Questionnaires were administered between July and November 2009, predominantly at respondents' homes. Questionnaire data were entered into Microsoft Excel for analysis.
Mass Vaccination Campaign Costs.
The mass vaccination campaign with Dukoral was implemented in the six selected Shehias in two rounds from January 17 to 26, 2009, and from February 7 to 16, 2009. Vaccination posts were erected within easy reach for the targeted population. Posts were run by local health care workers and villagers and open daily for at least eight hours. For each round, a total of 21 teams were needed to run the nine vaccination posts on each island. Each team consisted of six vaccinators. In addition, eight supervisors were deployed to Unguja and five to Pemba. The campaign was planned and implemented by the local Expanded Program on Immunization (EPI) team and international consultants deployed by the WHO. Social mobilization was done before and during both rounds by the MoH Health Promotion Unit.
Cost data on material (purchase, transport and storage of vaccines, cups and water), training and implementation required for the campaign were obtained locally from consultants and EPI. Because the campaign was planned and implemented within the scope of the research project, raw data were adjusted to exclude costs related to research. These costs were mostly incurred to train and compensate people at vaccination posts collecting data with electronic devices for parallel and subsequent epidemiological studies [28].
Cost-Effectiveness Analysis
Based on a previous study for Bangladesh [29], a model was developed in Microsoft Excel to estimate the costs and health effects of a mass vaccination campaign program compared to standard treatment in CTCs in Zanzibar. A static cohort of 50,000 individuals, reflecting the target population of the 2009 mass vaccination campaign in Zanzibar, was examined from a health care provider and a societal perspective. Input parameters for inclusion in the model were related to vaccine characteristics and vaccination costs, burden and impact of cholera, and public and private COI. Private providers were not considered since the majority of patients would visit public facilities in case of an outbreak [26]. Indirect effects due to herd protection were also included in the model since they may play a considerable role in the overall impact of cholera vaccination [30] and were shown to make community-based programs in three Asian and one African setting cost-effective [15].
The base-case model considered costs and effects of a one-time vaccination program over the duration of protection (i.e., three years). The annual number of cases without vaccination was obtained by multiplying the population size times the annualized cholera incidence obtained from surveillance of diarrhea cases with laboratory confirmation for cholera in the study area [31]. The annual number of cases under the vaccination program was derived from adding up direct and indirect effects of the vaccination program: direct effects were calculated by multiplying the annual incidence of cases without vaccination with (1 – protective efficacy among vaccinated people [PE]), coverage, and population size; indirect effects were calculated by multiplying the annual incidence of cases without vaccination with (1 – protective efficacy among unvaccinated people [PEU]), (1 – coverage), and population size. The variable PEU was derived using the concepts and a formula from Longini et al. [30] (p. 1778). It calculates what they refer to as "indirect vaccine effectiveness" = 1−(r01/r02), where r01 is the cholera incidence among unvaccinated people within a vaccinated sub-region and r02 is the cholera incidence in an unvaccinated sub-region. In the absence of incidence data among unvaccinated people from the mass vaccination campaign area, the incidence rate of 2.34 cases per 1,000 population (after annualizing, Khatib et al. [31]) calculated from people that resided in the lowest quintile of surrounding coverage (i.e., <39%) in a cluster with a radius of 400 m around vaccinated households was used as proxy for r02. Khatib et al. showed that herd protection effects mainly existed within that radius. A longer distance from the household of the vaccinated person was considered to dilute the benefit of herd protection. The incidence of 1.29 cases per 1,000 population (after annualizing) among all unvaccinated people was used as an approximation for r01 [31]. This leads to a base-case estimate of PEU = 45%.
The number of annual deaths without a vaccination program was calculated by multiplying the CFR with the annual number of cases without vaccination. The number of deaths with a vaccination program was calculated by using the CFR times the annual number of cases under the vaccination program.
Incremental cost-effectiveness ratios (ICER) calculated as incremental costs per death, per case and per disability-adjusted life-year (DALY) averted were used as outcome measures. Incremental costs were calculated as the difference between costs of the vaccination program and public COI saved due to the vaccination from the health care provider perspective. Private direct COI saved were added in the base-case model adopting the societal perspective. Private indirect COI saved were not included in the base-case model [32]. The number of deaths, cases or DALYs averted was equal to the difference in numbers with and without the vaccination program. DALYs, which are an aggregate measure combining morbidity (i.e., years of life lived with disability) and mortality (years of life lost), were calculated according to Jeuland et al. [15], assuming no age weighing. Since no disability weights are available for cholera, the disability weight of 0.11 for diarrheal diseases [33] was used. Life expectancy at the average age of onset of 18 years based on patient data was obtained from WHO life tables for Tanzania [34]. The vaccine was directly purchased from the manufacturer at a UN price. Future effects were discounted at a rate of 3.0% for the base case. Campaign costs were not discounted since the mass campaign happened over one single year.
Cost-effectiveness was examined according to widely-used WHO criteria that define an intervention as 'cost-effective' if the ICER is less than three times per capita gross domestic product (GDP) per DALY averted and as 'highly cost-effective' if the ICER is less than per capita GDP per DALY averted [35].
One-way sensitivity analyses were done to estimate the influence of changes in potentially influential input parameters on model outcomes. Such key parameters included vaccine purchase price and delivery costs, protective efficacy (PE, PEU), duration of protection, incidence, CFR and so forth [15]. Plausible ranges were based on public health considerations (for vaccine purchase price and delivery costs, incidence), guidelines (discount rate) and variation for local data (PE, PEU, CFR, number of ill days, public and private COI). Base-case values and plausible ranges are presented in Table 2. Threshold analyses examined at which vaccine purchase price the intervention would become cost-effective.
Public COI
Table 3 presents the fixed and variable mean public COI at the three CTC sites. Fixed costs of USD 51 accounted for 85% of public COI, with mean fixed costs ranging from USD 21 to USD 88. Direct and indirect human resources costs accounted for the majority of fixed costs; they were highest in Kiuyu Minungwini (86%), medium in Micheweni (85%) and lowest in Chumbuni (80%). The remaining fixed costs were used for setting up and running the centers. Health care personnel working in Unguja received higher top up payments than in Pemba, but the latter were given food to cater for themselves while on shift. Variable costs of USD 9.2 were mainly driven by IV fluid use as patients were administered on average 8.8 liters, which cost USD 7.1. Further details on public variable costs for treatment can be found as supporting information in Table S1.
Private COI
A total of 95 individuals were interviewed. All but one of the interviewed patients had been admitted at the CTC at Micheweni PHCC. Total direct and indirect mean private COI amounted to USD 43, with almost three-fourth (USD 32) being indirect costs (i.e., productivity losses to the patient or caregiver and other household members) (Table 4). Among direct costs, which amounted to USD 11, feeding the patient at the CTC accounted for the biggest share (USD 8.3, 19% of total costs). Other direct costs, incurred for treatment (mainly for plastic sheets needed to cover cots), transport and communication, were reported each by less than 3%.
Mass Vaccination Campaign Costs
Total mass vaccination campaign costs amounted to USD 760,000, with USD 510,000 (68%) spent on vaccine purchase and USD 240,000 (32%) on delivery (Table 5). The vaccine was purchased from SBL Vaccin AB, Sweden, at a price of USD 10 per course (2 doses). Delivery costs comprised transport of the vaccine from Stockholm to Zanzibar and procurement of cups and water required for the buffer solution (6.0% of campaign costs), the work of two experienced international consultants (14%), training of locally recruited implementers (1.3%) and the implementation (social mobilization and vaccination) itself (10%). More details on delivery costs are presented as supporting information in Table S2.
At a vaccine purchase price of USD 10 per course, the estimated total costs per fully immunized individual amounted to USD 30, with mean costs per vaccine course of USD 21 and mean costs for delivery of USD 9.7. The latter amounted to USD 5.3 after exclusion of services from international consultants, lowering the overall total costs per fully immunized individual to USD 26. Mean costs were adjusted for actual coverage of 50%, relating to 23,921 fully immunized individuals out of a population denominator of 48,178 used in the analysis by Khatib et al. [31].
Cost-Effectiveness Analysis
Base-Case Results.
Table 6 presents the results of the cost-effectiveness analysis from the health care provider perspective using base-case parameter estimates obtained from primary and secondary data sources from Zanzibar. Annual costs to immunize 50,000 people, if the OCVs cost USD 10 per course, were USD 430,000 assuming one campaign per three years at a cost of USD 1.3 million. Annual public COI averted by vaccination amounted to USD 4,000. Incremental costs, the difference between total annual costs (i.e., vaccination program and public COI) with and without vaccination, amounted to USD 430,000. ICERs were USD 750,000 per death averted, USD 6,500 per case averted and USD 30,000 per DALY averted.
Logistical on-site support from the WHO headquarters was provided since the campaign was conducted within a research project that aimed to assess also epidemiological and socio-behavioral aspects of OCV use in endemic settings. Thus, costs incurred for international consultants were excluded from the analysis on the assumption that the campaign would also have been possible without intensive external help.
The predicted ICER was much greater than three times the per capita GDP for Tanzania (USD 1,500 in 2009) per DALY averted [40], suggesting that mass immunization with OCV in Zanzibar was not cost-effective. Even if the OCV was donated to the government at no cost, the vaccination would still cost more than the avoided public COI due to the delivery costs; and the ICER would be USD 6,000 per DALY averted.
Compared to the health care provider perspective, key outcomes of the cost-effectiveness analysis from the societal perspective (Table S3), which included private direct COI, did not differ from each other.
Sensitivity Analyses.
One-way sensitivity analyses from the health care provider perspective were performed with input parameters presented in Table 2. This analysis does not account for the effects of non-linearity and interactions between uncertain parameters as it varies parameters one at-a-time while keeping other parameters at base-case values, and the ranges specified for each parameter may not reflect equivalent ranges of uncertainty [41]. Varying base-case values over plausible ranges helped to estimate the influence of parameters on the ICER per DALY averted (see Figure S1), and per death (Figure S2) and case (Figure S3) averted. The most influential parameters on the ICER per DALY averted were incidence, CFR, discount rate and vaccine purchase price.
In the absence of herd protection (i.e., if PEU = 0%), the ICER per DALY amounted to USD 48,000; and when assuming a herd protection rate as achieved in Zanzibar (PEU = 75%), the ICER of USD 24,000 still by far exceeded the criterion of USD 1,500, below which the intervention was defined as cost-effective.
Acknowledging that the incidence would have been higher than the base-case estimate used in the model if there had been no OCV campaign at all in Zanzibar, an annual incidence of 4.0 cases per 1,000 population from Beira was used as an upper bound in the sensitivity analysis. Even though the ICER was reduced to USD 18,000 per DALY averted at this incidence rate, the campaign was still cost-ineffective.
Threshold Analyses.
Another two-dose OCV was licensed for use in India in 2009. Shanchol (Shanta Biotechnics, Hyderabad, India) is a bivalent variant of Dukoral, containing killed V. cholerae O1 and O139, but no CT B subunit. It has recently been pre-qualified by the WHO for UN use; at its current price of USD 1.9 per dose to the public sector, it may become an attractive alternative for future OCV campaigns [22]. Analysis from three years of follow-up of a randomized controlled trial from Kolkata, India, showed that Shanchol has a protective efficacy (PE) of 66% across all age groups [42]. Repetition of the OCV campaign in Zanzibar with Shanchol at USD 3.7 per course and PE = 66%—ceteris paribus—would reduce the ICER to USD 16,000 per DALY averted from the health care provider and the societal perspectives.
In addition, changing vaccine delivery costs to USD 1.1 (being the minimum level used in this study), cholera incidence to 4.0 cases per 1,000 population and CFR to 1.9% (both parameters being at the maximum level) would further reduce the ICER to USD 3,300 per DALY averted from both perspectives. Based on these assumptions the purchase price of Shanchol per course would have to be as low as USD 1.2 to render the mass vaccination campaign cost-effective from a health care provider perspective (or USD 1.3 from a societal perspective).
This study estimated public and private COI due to endemic cholera in Zanzibar and costs of the 2009 mass vaccination campaign to assess cost-effectiveness from a health care provider and a societal perspective. The analysis presented here suggests that COI averted by a mass vaccination campaign with an OCV were negligible to the public health sector and the society and that such an intervention was not cost-effective based on the stated assumptions. However, mass vaccination campaigns in Zanzibar to control endemic cholera may meet WHO criteria for cost-effectiveness under certain circumstances of highly optimistic assumptions about vaccine purchase price, delivery costs, incidence and CFR. It should also be noted that the ICERs do not explicitly account for the indirect COI and the societal value of prevented premature deaths, which are implicitly captured in the effectiveness in terms of averted DALYs.
Private costs were higher than in Beira, Mozambique [13], where Dukoral had also been used in a mass campaign in endemic settings. Although mean public and private COI of USD 104 per episode were higher than the USD 47 for hospitalized cases in Beira, the mass vaccination campaign was not cost-effective in Zanzibar.
Relative costs for the vaccine and for delivery were comparable to findings from two campaigns in Vietnam with the bivalent Vietnamese OCV where this ratio was 25 vs. 75% in 1997 [43] and 21 vs. 79% in 1998 [12], respectively. However, due to the high vaccine purchase price, mean costs per fully immunized individual of USD 21 were much higher than previously reported costs of USD 0.5 to 10 from Sudanese refugee settlements in northern Uganda (1997) [44] and of USD 2.1 from Beira, Mozambique (2003), where the vaccine was provided free of charge [14].
Mean costs for delivery of USD 5.3 (after exclusion of costs related to international consultants) tended to be more in the range of previous campaigns in other regions; costs in the Zanzibar campaign were between the USD 3.3 reported for Darfur, Sudan (2004) [45], and the USD 8.6 reported for the mass immunization campaign in post-tsunami Aceh, Indonesia (2005) [46].
ICERs were well above any results reported for previous cholera mass vaccination campaigns [15], [29], [47]–[50]. The main reason why mass vaccination with Dukoral was cost-ineffective in Zanzibar may be due to using an expensive OCV in a relatively low incidence setting. Another reason may be that the present model used local data on costs of immunization. Other cost-effectiveness models that were not based on locally available data generally assumed much lower immunization costs, using (subsidized) vaccine prices of ∼USD 1 and delivery costs of ∼USD 1 per course; this made them propose that vaccination is economically more viable than standard treatment [15].
Also noteworthy in contrast to Jeuland et al. [15] is the finding that the inclusion of indirect effects in the model did not make the intervention cost-effective. The ICERs per DALY averted for both the base-case and the maximum estimate for herd protection were well above the WHO criterion for cost-effectiveness.
This study has several limitations. First, due to limited data availability, this cost-effectiveness analysis assessed the value for money of a population-wide OCV campaign and not of a targeted approach for high-risk or specific age groups, which might make the intervention cost-effective as shown by Jeuland et al. for school-based programs in Kolkata and Beira [15]. However, threshold analyses using Shanchol indicated that scenarios targeting high-risk groups may become cost-effective in Zanzibar if the OCV was procured at a price below USD 1.3, a level acceptable by many public health policy makers in Asia [36].
Second, it may be argued that the assumption of a preference for health facilities during a cholera outbreak may not necessarily reflect actual behavior as patients could also be negatively influenced by accessibility problems. Local observation and informal interviews, however, support this assumption, and the dense primary health care system reduces transport issues (according to the 2004/5 household budget survey, mean distance to a health care center in the urban and rural area was 0.4 and 1.7 km, respectively [17]) and because treatment for diarrhea is free.
Third, non-diarrhea patients were usually not treated or admitted by their local public health care facility during the time it operated as a CTC. People seeking treatment for non-diarrheal diseases (e.g., for malaria) during an ongoing cholera outbreak will have to bear extra direct and indirect costs related to additional travel or potential serious complications due to delayed treatment. These additional costs have not been included in the cost-effectiveness analysis due to a lack of relevant data; future studies in the area are advised to collect estimates on the costs of patients who are not able to get treatment at their usual center to assess the relevance of this 'crowding out' effect on cost-effectiveness.
Fourth, the ICER might have been overestimated because waning has not been included in the estimate for PE. Jeuland et al. have adjusted their estimate in year 3 down by 17% [15]. However, since this represents a limited effect, and since sensitivity analysis included a minimum PE of 47%, omission of waning as input parameter in the model is likely to have only a limited effect.
Fifth, threshold analysis for Shanchol did not consider potential savings due to the probably easier and faster administration of this new vaccine by oral syringe; this may have resulted in more favorable cost-effectiveness, but any beneficial effect will likely be limited because delivery costs influenced the ICER only to a small extent.
Sixth, even though uncertainty in input parameters was considered in one-way sensitivity analyses, no full probabilistic uncertainty and sensitivity analysis was conducted which would provide a more complete picture of the distribution of possible outcomes and may find that some combinations of assumptions lead to greater cost-effectiveness than identified in the one-way sensitivity analysis [38].
Finally, a cost-benefit analysis may provide more useful information to local policy makers than a cost-effectiveness analysis because it explicitly characterizes the monetary value of prevented disease. However, willingness-to-pay data were not available for Zanzibar and contingent valuation exercises were beyond the scope of this study. Also, since campaign coverage with the free OCV in Zanzibar was merely 50% overall [31] and the community demanded a free vaccine [51], not making the OCV available for free in future campaigns would further jeopardize vaccine effectiveness and thus make such a program even less economical.
The analysis presented here suggests that costs averted by a mass vaccination campaign with an OCV in endemic areas of Zanzibar were negligible when compared to standard treatment in decentralized cholera treatment centers. Mass vaccination was not cost-effective based on empirical data and the stated assumptions, mainly due to the relatively high purchase price and the relatively low cholera incidence in Zanzibar. However, mass vaccination campaigns in Zanzibar for endemic cholera control may meet WHO criteria for cost-effectiveness under certain circumstances, especially in high-incidence areas and when OCV prices are reduced to levels below USD 1.3.
Supporting Information
Figure S1.
One-way sensitivity analysis of the influence of key parameters on ICER in 2009 USD per DALY averted from model of mass oral cholera vaccination (health care provider perspective) in Zanzibar, 2009. Tornado diagram presents parameters that were varied over their plausible ranges, as shown in brackets. Vertical line indicates base-case ICER of USD 30,000 per DALY averted. ICER: Incremental cost-effectiveness ratio, DALY: Disability-adjusted life-year.
Figure S2.
One-way sensitivity analysis of the influence of key parameters on ICER in 2009 USD per death averted from model of mass oral cholera vaccination (health care provider perspective) in Zanzibar, 2009. Tornado diagram presents parameters that were varied over their plausible ranges, as shown in brackets. Vertical line indicates base-case ICER of USD 750,000 per death averted. ICER: Incremental cost-effectiveness ratio.
Figure S3.
One-way sensitivity analysis of the influence of key parameters on ICER in 2009 USD per case averted from model of mass oral cholera vaccination (health care provider perspective) in Zanzibar, 2009. Tornado diagram presents parameters that were varied over their plausible ranges, as shown in brackets. Vertical line indicates base-case ICER of USD 6,500 per case averted. ICER: Incremental cost-effectiveness ratio.
Table S1.
Public variable costs of illness for cholera, Zanzibar, 2009.
Table S2.
Delivery costs for a mass oral cholera vaccination campaign, Zanzibar, 2009.
Table S3.
Key outcomes from model of mass oral cholera vaccination (societal perspective) in Zanzibar, 2009. Base-case results from population of 50,000, with 3% annual discounting of effects.
We are grateful to the patients and caregivers in Pemba, who readily consented to being interviewed. We appreciate the hard work and commitment of Saleh J. Mohammed and Jamila K. Ali, who conducted these interviews. Thanks go also to the Zonal Medical Officers of Unguja (Dr. Fadhil M. Abdallah) and Pemba (Dr. Mkasha H. Mkasha), to the District Health Management Teams of Wete and Micheweni, and to the staff from Micheweni Hospital and Chumbuni and Kiuyu Minungwini Primary Health Care Units for providing cholera treatment cost data. We acknowledge support and access to unit cost data from Dr. Bou Peters (Danida) and Kai Straehler-Pohl and Moritz Piatti (MoH consultants). We are indebted to Valérie Perroud, Dr. Frédérique Marodon and Abdul A. Saleh, who were crucial in providing mass vaccination campaign cost data. Ramadhan Hashim, Benedikt N. Ley and Dr. Kamala Thriemer from the International Vaccine Institute are also acknowledged for their help during this study.
The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.
Author Contributions
Conceived and designed the experiments: CS MGW SMA CLC AMK RH. Analyzed the data: CS RJDT RH. Contributed reagents/materials/analysis tools: RR. Wrote the paper: CS RH. Collected data: CS. Facilitated data collection: SMA AMK RR. Revised the manuscript: RJDT. Final approval of the manuscript: CS MGW SMA CLC AMK RR RJDT RH.
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text:
WEST PLATTSBURGH - And, they're off.
The United Way of Clinton and Essex Counties Inc. officially marked the beginning of their 2009-10 fundraising efforts with their annual fundraising campaign kick-off breakfast at American Legion Post 1619 Sept. 10. The event included the announcement this year's campaign team will again seek to raise $700,000 to benefit the 33 partner agencies of the local United Way.
John C. Bernardi, the nonprofit organization's executive director, announced "pacesetters" - businesses and individuals who begin early fundraising efforts - have so far raised $151,426.62, bringing the campaign to 21.6 percent of its overall goal.
Bernardi credited the success of the campaign's start to the "good cross-section" of those in the community who continue to lend a hand to the United Way.
"We're well-represented and it's just a tremendous asset, I think, to be so strongly supported by such a wide range of groups and individuals," said Bernardi. "We're truly blessed in this region in many ways. Mainly because people get involved and they're compassionate and they're caring towards their friends and their neighbors. It really shows."
Though Wyeth Pharmaceuticals, which has facilities in Rouses Point and Chazy, has traditionally made a contribution toward the local United Way campaign, this year's donation was in question, said Bernardi. With the sale of the Wyeth corporation to pharmaceutical giant Pfizer Inc. announced earlier this year and transition of the Rouses Point facility to Akrimax Pharmaceutical currently under way, there was concern whether or not Wyeth would be able to continue to give, Bernardi said.
"I've been a little worried about it," admitted Bernardi. "And, it went from bleak to promising to bleak to promising to delightful, thankfully."
In the days leading up to the campaign kick-off breakfast, Bernardi learned Wyeth would indeed make a corporate donation of $32,521, and the employees of both the Rouses Point and Chazy facilities will again conduct employee fundraising campaigns.
Though there was no novelty check presentation from Wyeth as in years passed, company representative Tammy Lashway was in attendance for the breakfast, standing as Bernardi recognized Wyeth for the contribution.
Lashway later said the donation was part of Wyeth's continued commitment to the North Country.
"I think it's very important," she said of the donation. "We need to support our community."
Champlain National Bank also surprised Bernardi and the fundraising team this year, again nearly doubling their amount raised. The bank's employees raised $2,000 in the 2006-07 campaign year, doubling that amount the following year and doubling that amount the year after.
Given the state of the national economic climate and that Champlain National Bank had a recent reduction in its number of employees, Bernardi said he didn't expect the business to be able to raise as much as in previous years. But, they did.
"We just figured they were maxed out. I mean, you can't double it every year. It's not realistic," said Bernardi.
Gail Bridge, human resources director for Champlain National Bank, said bank president Jon Cooper challenged his employees to do just that, and they came close.
"We showed him what his team can do. We raised $15,000," said Bridge.
More big news came from Nine Platt Hospitality Group, which raised $10,121, which was the largest amount from the local business in the past seven years.
Other pacesetter contributions include Abbott, Frenyea, Russell & Coffey, $1,899; Agency Insurance, $1,855; Alan B. & Jennifer Booth, $3,500; Child Care Coordinating Council of the North Country, $2,792; Donlan and Barcomb Investment Services, $1,000; Eye Care for the Adirondacks, $10,007.10; FirstView Eye Care, $1,000; Landrock E & S Consulting, $1,000; Mountain Lake PBS, $378; Murnane Building Contractors, $2,000; Niles, Piller & Bracy, Attorneys at Law, $750; Northern Insuring Agency, $9,000.08; and Stewart's Shops, $1,800.
The Child Care Coordinating Council of the North Country and Northern Insuring Agency were also recognized for having 100 employee participation.
Partial contributions to date include Denton Publications, $5,200; ETS, $1,040; Georgia Pacific, $8,253; Plattsburgh City School District, $4,210; TD BankNorth, $3,600; The Northeast Group, $1,500; and UPS - SCS, $6,890.
Additional contributions from individuals and other miscellaneous organizations total $26,110.44.
The amount raised thus far is encouraging, said Jamie L. Basiliere, executive director of the Child Care Coordinating Council of the North Country, who serves as chairperson of this year's United Way fundraising campaign team.
"I believe that we will exceed the goal," said Basiliere, who is serving the campaign team for her 11th year. "I believe for those people who are employed, who have a campaign within their organization or within their business, that they will give because of the economy, not in spite of it."
Though pacesetters are an important part of getting the campaign moving, said Bernardi, every donation is just as important as the last, he noted.
"Every penny is important," said Bernardi, "whether it comes in today or whether it comes in in December."
Those wishing to make contributions toward the local United Way campaign may send donations in care of United Way of Clinton and Essex Counties to 45 Tom Miller Road, Plattsburgh N.Y. 12901. Donations may also be arranged through a payroll deduction, which may be arranged through one's employer.
For more information, contact the local United Way office at 563-0028 or visit www.unitedwayce.org.

subset: commoncrawl


text:
Antonio Conte's men warmed up for this meeting with an emphatic 4-0 thrashing of Udinese at the weekend and Juventus are available at just 4/7 (1.57) with Bet365 to take a step towards the final by defeating Lazio here.
Petkovic's side were held by Palermo at the weekend but have not lost in any competition since slipping to defeat against Catania at the beginning of November.
They are available at a tempting 5/1 (6.0) with Bet365 to take victory in Turin with the same firm offering 11/4 (3.75) that the match ends in a draw.
The Bianconeri were beaten in last year's final by Napoli and Bet365 go just 4/9 (1.44) for Conte's men to take their place in this year's final while the Biancocelesti are available at 13/8 (2.63) with the same firm to qualify for the final.
It is worth noting that Petkovic's men have kept five clean sheets in their last eight competitive matches and are capable of keeping things tight against a Juventus side that has won just one of their last four games inside 90 minutes.
With that in mind, the 19/20 (1.95) on offer from Bet365 for fewer than three goals to be scored looks to represent decent value and could be worthy of support.
Both sides are likely to be missing key protagonists for this clash but it is the hosts that appear to be most hampered by injury and the 7/5 (2.40) on offer from Bet365 for Lazio (+1) in the handicap market is outstanding value and simply must be snapped up here.
With just five points separating the two clubs at the top of Serie A, the disparity in match odds seems disproportionate and the draw, available at 11/4 (3.75) with Bet365, is superb value in what promises to be an evenly-matched contest.
|Lazio (+1) to win at 7/5 (2.40) with Bet365
|Draw at 11/4 (3.75) with Bet365
Sign up with Bet365 for up to £200 in free bets
Willie Duncan is a freelance sports journalist. Willie, from Edinburgh, has covered Scottish football for over 10 years and he specialises in football betting markets from across Europe. You can also follow Willie on Twitter


text:
Wall-based New Jersey Resources announced on Wednesday that its board has authorized it will add 1 million shares to its repurchase program.
The number of authorized shares has been increased a total of seven times, including today's announcement, to a current level of 9.75 million shares. To date, 8 million shares have been repurchased under the program.
The program has been in place since 1996 as a means of providing the company with capital management flexibility.


text:
If you though the iPhone was big in China, think again. Gartner says that despite landing a deal with China Telecom, Apple has only a third of Samsung's smartphone market share. Samsung currently holds 24.3%, while Apple currently commands 7.5% of Chinese smartphone owners. Gartner says that the situation won't change without support for China Mobile, the biggest carrier in the country (and the world, for that matter).
As is, Apple will be able to reach 34% of the Chinese market, leaving about 655 million consumers outside of their reach. Even without official support, 15 million China Mobile subscribers are apparently willing to live on 2G and Wi-Fi so long as they get to use an iPhone 4S.
Although it's unfortunate for Apple that they're missing out, they haven't bothered to make an AWS-compatible iPhone to address the entire U.S. market, so it's not entirely surprising that they aren't willing to make a TD-SCDMA iPhone either. Maybe once China rolls out LTE Apple will be able to address the entire market there.
Yes, Apple is still dominating in global profit share, but with Apple's margins, every point of market share brings with it a huge amount of profit share, and in China they're just not exploiting it to its full potential yet.
Source: Bloomberg


text:
Get The Help You Deserve
Find A Therapist connects you with licensed mental health professionals including psychologists, clinical social workers, marriage and family therapists, psychiatrists, and professional counselors.
We understand that admitting the need for help is the first step toward improving your life, but finding the right therapist can be difficult. We have made it easy to search for a local therapist and send them a secure confidential message. You can be assured your privacy is respected and protected while finding the help you deserve.


text: We resell a high-end CAD package that uses OpenGL. We have been using the ASUS V6600 & V6800 cards and have noticed that after opening a third window in this application, the system seems to switch to software based OpenGL. This initial sign of the problem is that the screen is repainted diagonally from the upper left to the lower right in several bands. I have seen other articles posted that suggest this is happening in other applications. This application does not have this problem using GLint based cards such as the GVX1 by 3D Labs. I too have sent e-mails to NVIDIA and ASUS tech support. I have not received any responses. It's too bad. We have found that the performance of the board is faster than cards twice its price! I did notice that dropping the # or colors to 65K will allow us to open more windows before we run into the problem. I tried the WIN.INI (VDA=0) but we are running NT. Is there a registry hack equivalent? Also does anyone know what the available registry entries are for these cards? Is anyone else using the GeForce with CAD apps?


text:
The U.S. Department of Justice and 33 U.S. states and territories proposed those changes after U.S. District Judge Denise Cote in Manhattan last month found in a civil antitrust case that Apple played a "central role" in a conspiracy with the publishers to raise e-book prices.
The DoJ also requires that competitors such as Amazon and Barnes & Noble be allowed to include links to their own stores in their iOS applications, which Apple had prohibited.
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Ebook below cost ? You should explain me how the price tag of a thin air based book is set, beside the author's fee and distribution (hrum, web hosting) margin.
Do you know what a author gets from a $50 paper edition ? You'll be surprised that like milk producing facilities, the one that do produce get the most little part. Something between $1 to $4 per book.
Ebook ? It's almost producer to consumer, no physical support (beside memory and mass media paid by the consumer) but it still costs a lot for what it is, and the author still gets only a tinny part of the price.
Until the author get the main part of the price, books will be too much expensive, period.


text:
Monday July 9, 2012
Royal fans and car enthusiasts alike will get the chance to snap up vintage motors once owned by Prince Rainier of Monaco, when pieces from the late principality ruler's collection go under the hammer.
Prince Albert is selling 38 models as he wishes to "reorganise" the royal fleet and add new pieces.
The auction will take place on July 26 at the Museum Terrasses de Fontvieille in Monaco.
Vehicles being sold include Prince Rainier's Mercedes 500 SEC which was one of his favourites.
An impressive Porsche 928 S, which is expected to fetch £312,000, is also up for grabs.
The late principality ruler was passionate about cars, and assembled a fleet of 100 models over 30 years before his death in 2005.
Read full story
Photo: © Rex Features


text:
Style # 212701
Spring into action by showing off your love for bebe in a bright dose of color. This top features a luxe Swarovski-embellished logo and high V-neckline. Try it with anything from a pair of denim shorts to a pair of coated denim.
- 48% polyester, 47% rayon, 5% spandex
- Center back to hem: 23" (58 cm)
- Swarovski crystals
- Hand wash
- Made in USA
- Model is 5'9" and is wearing a US size S
Logo Hanger Double V Stripe Tee is rated out of 5 by 1.
Rated 4 out of 5 by HollyJ from Soft and comfy This shirt is very soft and machine washable. The crystals sparkle and stripe combo is unique. Overall the fit is a bit larger compared to other bebe tops. I'm a size xs/s and the xs fits a bit big on me, but still looks great. I recommend ordering one size down.
Date published: 2013-07-09


text:
I'm a video guy. I love taking video, editing, and creating a unique experience for an audience. I've liked film and video ever since I was a kid.
I'm a video guy. I love taking video, editing, and creating a unique experience for an audience. I've liked film and video ever since I was a kid.
My parents introduced us kids to film when we were very young. We had an 8mm film camera, with no audio. Most of my friends who are my age aren't lucky enough to have such film from when they were young children. I have movies of me learning to ride a bike, flying a kite, and playing outside in the plastic kiddie swimming pool with my siblings.
When I was around ten years old, my parents purchased a beta video camera. It took color video and included audio! I immediately took to this new piece of technology. It was big, heavy, and took a battery about the size and weight of a brick. And at the time, I had never seen anything so cool in my life.
I began shooting video of everything – the front yard, our dog, and even myself in the mirror. Much like how kids today are glued to their cellular phones, I wanted to take our beta camera with me everywhere.
One of the things I enjoyed most was learning new techniques on how to use the video camera. I taught myself lighting effects, special camera angles, and how to create stop-motion animation. It was so much fun.
Eventually, we moved into a VHS camcorder, which would allow us to actually play-back the video on the camera. And whenever I had the chance, I'd video something.
For Christmas this year, I decided to dub all of our old video tapes to DVDs. I'd then create a DVD set for my father, brother, and sister of all of our old video from years past. I collected nearly a hundred beta and VHS video tapes from my father. I spent a couple months bidding on beta players on eBay, so I could play these old tapes from my childhood. Then, I spent about half a year dubbing the video to digital format, editing, cleaning it up, fixing the audio, and arranging the video into a complete DVD set containing nearly two dozen re-mastered DVDs with around 20 hours of footage.
We now each have a digital copy of all of our childhood film and video. Some of this video has never been seen before. It was recorded, the tape was not marked (big surprise), and put on the shelf to collect dust for the past 30 years.
I found video that none of us remember taking. I found video of people we haven't seen in years, and some of people we've lost. To see my mother on video, giving me a big hug when she was the age I am now, is simply amazing. And, it's a treasure.
But when I went through hour after hour of video, there is one thing I learned...
Everyone should buy a tripod and USE IT!
Watching our old video tapes, we actually did it correctly most of the time. Since the cameras back then were so heavy and large, holding it on your shoulder wasn't very comfortable. My father, who was a pretty smart guy back then, also purchased a tripod. We used it much of the time. But when we didn't use the tripod, it's all you can do to try to not get sick. All the shaking and fast, jerky movements make it hard to watch.
A tripod is a cheap investment. They are compact, light, and easy to setup. Yet, most people today don't use them. Just look around at the next basketball game or school concert. Dozens upon dozens of camcorders will be recording the event from every angle – and I bet you don't see many (if any) tripods!
I realize a tripod doesn't fit every occasion when you want to take some video, but when you can use a tripod, you should.
So do your audience a favor (which will probably be your kids, grandchildren, and future family), and create memories they can watch and cherish for years to come... and that won't require airsick bags!
For goodness sake, use a freakin' tripod!
Scott McCoy


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NEW YORK — ESPN says it's parting ways with Keith Olbermann as history repeats itself.
While praising Olbermann's late-night sports show on ESPN2, the network said Wednesday it has made "a business decision to move in another direction." It provided no details or further explanation for the program's cancellation, but wished him "nothing but the best."
It said the program, "Olbermann," will end sometime this month.
ESPN's announcement came two years after 56-year-old Olbermann returned to the network years after his tumultuous but star-making stint as a co-host of "SportsCenter" that ended bitterly in 1997.
In between, he...


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Lakeland Catholic School District No. 150
Invites applications for a
Grade 7 French Immersion Teacher
Dr Bernard Brosseau Middle School
Bonnyville, Alberta
If you love working with young students in a Catholic learning environment where teachers work collaboratively to create the best possible learning experience for students, this is the position for you. This position will commence on August 27th, 2014.
Candidates who are committed to Catholic Education are invited to apply. Your resume should highlight personal and professional qualifications, relevant experience and your most recent professional evaluation. Please email or fax your resume, three references and a pastoral letter to:
Lakeland Catholic School District
c/o Diane Bauer, Associate Superintendent
4810 - 46 Street, Bonnyville, AB T9N 2R2
Applications are also accepted through Apply to Education.
We thank all applicants for their interest. Only those chosen for an interview will be contacted.


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We want you to love it! If you don't, we've got you covered. Read the Younique Love It Guarantee here.
Royalty Shine Cleansing Cloths
Swipe Shine to remove makeup and cleanse skin
- Details
- Directions
- Ingredients
Tetrasodium Glutamate Diacetate: a binding agent
Gluconic Acid: broad spectrum natural preservative
Sodium Benzoate: broad spectrum natural preservative
Sodium Citrate: buffering agent to provide pH control
Olea Europaea (Olive) Fruit Oil: contains antioxidants that may help protect the skin. Moisturizes and softens the skin.
Simmondsia Chinensis (Jojoba) Seed Oil: an emollient that moisturizes and soothes dry skin
Helianthus Annuus (Sunflower) Seed Oil: an emollient rich in Vitamin E. Moisturizes and soothes skin.
Tocopherol: vitamin E that counteracts free radical formation, provides nutrition, and helps moisturize the skin
Oryza Sativa (Rice) Bran Extract: conditions skin, rich in antioxidants, helps maintain the suppleness of the skin
Tocopheryl Acetate: an antioxidant that supports the skin's response to UV light from the sun
Cyclopentasiloxane: a transient emollient that soothes and softens the skin
Polysorbate 20: a surfactant that is used as an emulsifier. Mild cleanser.
Fragrance: masks or imparts odor+
Rosmarinus Officinalis (Rosemary) Leaf Extract,
Sodium Hydroxide.
See Ingredient List
Expected availability date:
*This is the approximate date that back-orders will begin to be filled. The date that your specific backorder is filled may be several days later. If you wish to cancel your order prior to shipment, please contact customer service to obtain a full refund
Nature. Love. Science.
Younique's cosmetics development processes utilize scientific research to ensure that our products contain high quality ingredients that enrich and nourish the skin. The result is a beautifully efficacious product that is safely compatible with virtually every skin type.
Younique begins by looking to Mother Nature for the inspiration behind our cosmetics. Our in-house scientific team then formulates a product that honors that inspiration while delivering cutting-edge cosmetics. Our goal is to provide healthy, clean, and pure cosmetics.


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Friday, May 10, 2013 - Terry and Ivo - Screen Test - FULL CONTACT
Latest Sets at WilliamHiggins.com
Terry Torson came in for a screentest. He is a reall handsome, well built guy, so we paired him up with another very hot guy, Ivo Kerk. Ivo does a brief interview with Terry before they get going. Then they start to kiss each other. As they kiss they each rub the other's crotch, with hands going into the underwear to feel cock. Ivo then moves down and kisses on Terry's chest. Terry does the same for his new buddy. Ivo releases Terry's big cock from his underwear. It is rock hard and ready for action as his underwear comes off. Ivo goes down on that big cock and sucks on it. His lips wrapped tight around the head, he suck up and down on it, licking and kissing it as well. He sucks on Terry's balls too as he continues to work the dick. Terry loves the feeling and hold Ivo's head in place as he starts to fuck the mouth. Ivo then lays on the bed and Terry moves so that he can suck cock too, after removing Ivo's underwear. He really knows how to suck and works that cock very well with his mouth and tongue. He then sits, with one leg along Terry's body, so he can wank both their cocks. Ivo turns his head and kisses Terry's foot as his cock is wanked. Terry sucks that cock some more and then lifts Ivo's legs and begins to rim his hairy ass. Ivo is enjoying that tongue action and Terry kneels and slides his rock hard cock into that wet hole. That big cock slams in and out of Ivo's hot hole, and he moans as he takes it all, his own stiff dick moist on his belly. The Terry sits on the bed and Ivo slides is cock down on that throbbing dick. He rides up and down on Ivo's cock and then holds still so Ivo can really fuck him hard and fast. Ivo wanks his cock as he takes that big dick. Changing back to missionary Terry slam his dick in and out of that ass, with Ivo waning himself fast, and shooting his cum all over his belly. Terry pulls out and quickly wanks himself to a climax too over Ivo's cock and balls to end a magnificent screentest.
Robert Drtina is aged 18 and lives in Doksy. He is a student who enjoys fitness, athletics and sports generally. What a great looking guy Robert is. After his interview he kneels on the bed, in just his underwear. He runs his hands all over his hot, well-built chest. Then he stands up and shows his full length body, turning with his back to the camera. Robert reaches round and pulls the underwear off his ass cheeks, and up into his crack. That ass is nicely shaped as he exposed the cheeks. Turning around again Robert dips a hand into the underwear and turns his head to kiss a bicep. He looks magnificent as he stands and feels himself, squeezing his groin. He allows his cock out of a shorts leg, and the balls as well. He takes hold of the cock and wanks it a little. As he releases it we see that he is quite hard. Then Robert shucks the underwear down so we can see everything. He gets his cock rock hard, so it pokes out very well. Then he turns around and bends over to show off that hot ass. The hands spread his ass cheeks exposing his tight hole beautifully. That ass crack, lined with hair, in most inviting. Robert goes onto his knees,and shows the ass some more, with his cock nicely trapped between his huge thighs. Turning over, onto his back Robert shows that hole some more and then settles down to wank his cock. He quickly gets it rock hard again and shoots a nice creamy load over his body. Then it is off to the shower, to clean up.
In a fully remastered version of Inside Jirka Gregor Scene 2 we have Jirka Gregor, Franta Burian, Kristian Dubcek and Zdenek Langer. Jirka and Kristian are in the country by a lake. We find them naked and entering the water, right by a sign which says NO SWIMMIMG. As they play in the water we watch two policemen, Franta and Zdenek walking along the pathway towards the lake. They see Kristian and Jirka in the water, and stand a watch for a while. Next we find all four in an empty building. Kristian and Jirka are still naked and are being shouted at about swimming where it is not allowed. First Kristian is made to suck Jirka's cock, which is hard very quickly. As he sucks that cock Zdenek and Franta rub there pants and pull out their own cocks. They wank themselves as Kristian continues to suck. Then Jirka is told to suck Kristian. He goes down and sucks on his friends cock whilst wanking himself. Kristian is made to wank Zdenek's hard cock at the same time. Then Kristian has to suck on Zdenek's big cock, with Jirka doing the same to Franta. Both policemen are rock hard as their prisoner's lick and suck them. With their pants off Zdenek lays down and Franta kneels by him so that Kristian can suck them both. He works on each of the throbbing cocks and then is replaced by Jirka who takes both cocks in his mouth at the same time. Then Jirka is on his back with Kristian laying over him, so they can 69. Zdenek slaps Kristians ass with his nightstick as the sucking continues. The policeman stand by Kristian and slap his ass with their cocks, then Zdenek pushes his dick into Jirka's mouth alongside Kristians. The policemen are ready for more and postion their prisoners for fucking. Franta shoves his dick into Jirka's hot ass with Kristian taking Zdenek's deep too. They fuck their prisoners well and then move them around so that Kristian can fuck his buddy. As his cock works in and out of Jirka's ass Kristian feels Franta's dick sliding into his hole too. Jirka sucks on Zdenek's dick while taking Kristian deep in his hole. Changing positions again has Jirka on his back with Zdenek pounding his hole as Kristian is bent over so that Franta can fuck him too. With all this fucking the guys are ready to blow and Franta is first to cum, shooting his load over Kristian's hot ass. Zdenek pulls out and dumps his cum on Jirka. Kristian then cums over his friend as well. Finally Jirka wanks himself to a very nice climax as well. As we leave them we see that Jirka and Kristian have turned the tables on the policemen, handcuffing them together and to a ladder. This is a very good scene indeed, with four really hot guys.
Jano Drotar is from Dubrica in Slovakia. He is aged 20 and works as a carpenter. In his spare time Jano enjoys sports, fitness and karate. What a very handsome guy he is. As he removes his tee-shirt we see a nicely developed body too. Jano lays down to remove his pants. In the process we see his gorgeous ass, with the cheeks spread exposing his hot, tight hole. Pulling the cheeks further apart gives a better look at that hole. Then Jano shows his cock. At first soft and laying on his leg and then rock hard and pushed up towards the camera. Jano stands and poses with that cock rock hard and pointing skywards. What a beautiful sight he is with his cock so hard. He then goes through a series of poses to ensure we see everything of him, and get to enjoy it all. Jano has really whetted my apetite for his video shoot when it comes online next week.


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EboneHoodrich (Feat. Young Gunna, Veto) - Kush Blunts [Unsigned Hype]
Directed by Young Wonder
Chicago's Ebone Hoodrich Back wit another trap banger (Kush Blunts) feat. Young Gunna & Veto Stay Tuned "Books and Kush" cummin soon!!!!!!!!!!!!!
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Here are some websites that may have helpful breastfeeding information. Suggestions welcome!
LLL sources
LLLI Breastfeeding Help
LLLI Recommended Book List
Online issues of Breastfeeding Today - LLLI member magazine
Online issues of New Beginnings - LLL USA member magazine
The Womanly Art of Breastfeeding Toolkit - downloadable PDFs of the reference pages from the back of the book
The sites below are not associated with LLL. We try to make sure to link only sites that are reputable and contain accurate information, but we of course can't guarantee they'll remain up-to-date or that everything in them is correct.
General breastfeeding information
KellyMom.com - Breastfeeding and parenting site run by Kelly Bonyata, IBCLC Breastfeeding Made Simple - Website of IBCLCs Nancy Mohrbacher and Kathleen Kendall-Tackett, associated with their book Breastfeeding Made Simple: Seven Natural Laws for Nursing Mothers BreastFeeding Inc - Dr. Jack Newman's site Common Sense Breastfeeding - Articles by Diane Wiessinger, co-author of the latest edition of The Womanly Art of Breastfeeding
Medications and breastfeeding
InfantRisk Center - Information on the use of medications during pregnancy and breastfeeding from Texas Tech University Health Sciences Center LactMed - free online database with information on drugs and lactation from National Library of Medicine
Special situations
The Adoptive Breastfeeding Resource Website - created by a mom who breastfed her two adopted children BFAR.org - Breastfeeding after breast or nipple surgery; associated with the book Defining Your Own Success: Breastfeeding After Breast Reduction Surgery by Diana West, BA, IBCLC LowMilkSupply.org - Outgrowth of BFAR, along with the book Making More Milk: A Mother's Guide to Milk Supply by Diana West, BA, IBCLC, Lisa Marasco, MA, IBCLC, and Carol Maranta MOBI Motherhood International - Support for mothers with extraordinary situations that hinder or prevent breastfeeding
Evaluating medical information on the web
How to Evaluate Health Information on the Internet - Questions and answers from the US National Institute of Health Office of Dietary Supplements. Health Information on the Internet - What to look for when evaluating the reliability of health websites, from Neurologica Blog. Recognizing Dubious Medical Devices - The article focuses on medical devices, but the same principles can be applied to evaluating any medical or herbal treatments or dietary supplements. From Science-Based Medicine.
Other useful websites
ISIS (Infant Sleep Information Source) - Evidence-based information on normal infant sleep