1. HCV Transmission and Tattoo Parlors Is it cost-effective to regulate tattoo parlors to reduce the spread of HCV? At what prevalence level is it cost- effective?

2. HCV 3.1% of world infected with HCV –20% of recruits in Egypt Expected to kill more Americans than HIV Transmitted through blood –Transfusions, sex, mother-child, unsterilized medical equipment, injection drug use, … –Most frequently through needle sharing (developed countries) –Transfusion now screened What about tattooing? –Conflicting data.

3. Model Compartmental infectious disease model –With costly control Similar to HIV but –HCV more infectious –HCV infection less costly Considers both tattoo and non-tattoo modes of transmission –Not additive

4. States 3 health states –S = Susceptibles –A = Acute infection –C = Chronic infection 2 social states –t = visits tattoo parlors –o = doesn’t 6 total states: S o,S t,A o,A t,C o,C t

5. Non-tattooed population  A,  C death rates r AS, r AC, r CS transition rates  S death+turning 50  = overall prevalence  rate of non-tattoo transmission Time in years Population = age 15-50 SoSo AoAo CoCo ss r AS r AC r CS  AA CC

6. ss k = flow of people turning 15 g = rate at which people not interested in tattoos  = annual rate of getting tattoos

7.  = P(infection | infected equipment)  = P(equipment infected) =  ·f(  t )  = P(use of equipment on HCV+ person infects equipment) f(  t ) = P(use of equipment on HCV+ person) –Typically equipment used 5 times before replaced –f(  t ) = (1/5) ∑ i=0..4 1-(1-  t ) i

8. ss  t =(A t +C t )/(S t +A t +C t )  =(A o +A t +C o +C t )/total

10. Control Control is sterilization of equipment –  = 0 (or close to) Time –  = time of regulation –T = planning horizon (15 years in baseline) Discounting (3% in baseline) Outcomes –  ( ,T) = total discounted number of sterilizations –I( ,T) = total discounted number of infections

11. Cost-effectiveness Cost –  = cost of sterilization –  = cost infection –Not really accounting for health quality Regulate at time t 2 versus t 1 Benefit/Cost ratio [$]/[$] –BC(t 1,t 2 ) = (I(t 2,T)-I(t 1,T))/(S(t 2,T)-S(t 1,T)) ·  / 

12. Base Case

13. Uncertainty in 

14. Is a dynamic model needed?

15. Conclusion and Discussion Regulating tattoo parlors is cheap and cost- effective Doesn’t capture averted secondary infections beyond horizon More tattoos (  ) may decrease BC Dynamic model crucial to capturing secondary infections Would an age structured model make sense? What about HIV?

16. Next Time Network models: the effect of reducing concurrency on HIV transmission…