Dengue is an increasing public health concern in Brazil. There is a need for an updated evaluation of the economic impact of dengue within the country. We undertook this multicenter study to evaluate the economic burden of dengue in Brazil.
We estimated the economic burden of dengue in Brazil for the years 2009 to 2013 and for the epidemic season of August 2012- September 2013. We conducted a multicenter cohort study across four endemic regions: Midwest, Goiania; Southeast, Belo Horizonte and Rio de Janeiro; Northeast: Teresina and Recife; and the North, Belem. Ambulatory or hospitalized cases with suspected or laboratory-confirmed dengue treated in both the private and public sectors were recruited. Interviews were scheduled for the convalescent period to ascertain characteristics of the dengue episode, date of first symptoms/signs and recovery, use of medical services, work/school absence, household spending (out-of-pocket expense) and income lost using a questionnaire developed for a previous cost study. We also extracted data from the patients' medical records for hospitalized cases. Overall costs per case and cumulative costs were calculated from the public payer and societal perspectives. National cost estimations took into account cases reported in the official notification system (SINAN) with adjustment for underreporting of cases. We applied a probabilistic sensitivity analysis using Monte Carlo simulations with 90% certainty levels (CL).
We screened 2,223 cases, of which 2,035 (91.5%) symptomatic dengue cases were included in our study. The estimated cost for dengue for the epidemic season (2012–2013) in the societal perspective was US$ 468 million (90% CL: 349–590) or US$ 1,212 million (90% CL: 904–1,526) after adjusting for under-reporting. Considering the time series of dengue (2009–2013) the estimated cost of dengue varied from US$ 371 million (2009) to US$ 1,228 million (2013).
The economic burden associated with dengue in Brazil is substantial with large variations in reported cases and consequently costs reflecting the dynamic of dengue transmission.
The World Health Organization estimates that 50–100 million dengue infections occur annually. However, estimates based on cartographic modeling approaches suggest that up to 390 million dengue infections annually. Dengue has become an increasing public health concern in the Americas. A substantial number of cases in the Americas are reported in Brazil. There is a need for an updated evaluation of the economic impact of dengue in Brazil so as to allow decision/policy makers to make informed decisions on resource allocation and strategic planning. We estimated the economic burden of dengue in four regions. National cost estimates were based on the number of cases reported in Sistema de Informacao de Agravos de Notificacao (SINAN). Overall, 2,035 (91.5%) dengue cases were recruited to our study. More than 2 million suspected dengue cases and 569 deaths were reported in SINAN from September 2012 to August 2013. The annual national economic burden was US$ 164 million from the public payer perspective, but may be as high as US$ 447 million (adjusting for underreporting). From the societal perspective, the economic burden was US$ 468 million, but may be as high as US$ 1,212 million. The economic burden associated with dengue in Brazil is substantial.
Data Availability: All relevant data are within the paper, its Supporting Information files, and at http://www.cpqam.fiocruz.br/custodengue/.
Funding: Funding for this Study was provided by Sanofi Pasteur. CMTM and WVdS received fellowship grants (CNPq# 306489/2010-4, #305947/20060). CMTM, WVdS, CB, and JBSB are research members of the National Institute of Science and Technology for Health Technology Assessment (IATS). ALdSAZ, FC and NTdSF received scholarships from CNPq/IATS. CMTM, ALdSAZ, MPPDP, FC, NTdSF, FGJP, MCOM, LRB, MQMdR, CSO, CB, and JBSJ received funds to their institutes from Sanofi Pasteur to support their work in the Multicenter Cost Study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: JGL is an employee of Sanofi Pasteur. This does not alter our adherence to all PLOS policies on sharing data and materials. The other authors have declared that no competing interests exist.
Dengue is a viral infection transmitted by Aedes mosquitoes, with global distribution, mainly in the tropical regions . Infection with one of the four antigenically distinct dengue serotypes (serotypes 1, 2, 3, and 4) is often asymptomatic/inapparent or mildly symptomatic, but has the potential to escalate to dengue fever and subsequently, to life-threatening dengue hemorrhagic fever or dengue shock syndrome, and death. Although life-long immunity to the infecting serotype may develop, the more severe or life-threatening cases of dengue are more often associated with subsequent secondary infection by heterologous dengue serotypes .
Contemporary global estimates from the World Health Organization suggest that 50–100 million dengue infections occur annually .A more recent estimate, based on cartographic modeling approaches and data from various published sources between 1960 and 2012, suggests that there are about 390 million dengue infections per year with 96 million apparent/symptomatic cases of the disease . Although the majority of dengue infections occur in Asia , there has been a dramatic increase in the number of reported dengue cases in the Americas over the last decade [4–6]. Over 50 million dengue infections were estimated (using cartographic modeling approaches)in the Americas in 2010, and of these, about 40%(21.8 million infections) occurred in Brazil . Recent surveillance data from the Brazilian national notifiable diseases information system (SINAN; Sistema de Informacao de Agravos de Notificacao) showed that there were more than 2 million dengue cases reported in 2013, the highest annual incidence registered in Brazil since dengue surveillance was implemented in the 1980´s . The increase in the incidence of dengue was probably due to the introduction of dengue serotype-4 along with the rapid spread and co-circulation of the other serotypes (serotypes 1, 2, and 3). In addition, the reporting rates may have increased due to higher dengue awareness among the population and the health workers.
Dengue can impose a significant economic and humanistic burden in countries where the disease is endemic and, as such, estimating the associated economic and disease burden can help inform policy makers and assist them in setting priorities for disease-management strategies and for the introduction of new technologies . To date, there has been one previous cost evaluation of the economic burden of dengue episodes in Brazil (undertaken only in the Midwest region, city of Goiania in 2005), which was part of an international study that included five countries in the Americas (Brazil, El Salvador, Guatemala, Panama, and Venezuela) , and was subsequently updated as part of a later study . These previous evaluations, however, estimated the cost of dengue cases without taking into account seasonal fluctuation or costs associated with dengue outbreaks. Nonetheless, the estimated cost of dengue illness across the Americas between 2000 and 2007 was substantial, at US$2.1 billion per year (2010 US$), with the majority of costs associated with ambulatory cases rather than hospitalized cases and with substantial year to year variation . Brazil accounted for about 40% (US$878.2 million) of the total costs in the Americas. Since these publications, recommendations and guidelines have been developed for estimating the burden and socio-economic costs of dengue [11–13]. There is marked variation in dengue transmission across time and by serotype circulation, as previously published [14–18]. As such, there is a need for an updated evaluation of the economic impact of dengue in Brazil that also includes more regions within the country and adheres to the new guidelines and recommendations.
The Brazilian health system is a complex mix of both public and private sectors [19, 20]. A cost evaluation needs to consider the perspective of both sectors . The aim of this study was to evaluate the economic burden of dengue from the public payer and societal perspectives across four endemic regions in Brazil, and to extrapolate these costs to the whole country.
This was a prospective, multicenter, observational study aimed at measuring the direct and indirect costs associated with dengue illness across six sites in four endemic regions of Brazil. The time horizon of analysis was one year, from September 2012 to August 2013, which takes account of dengue seasonality.
The protocol was approved by each centers' Ethical Committee and registered at the Brazilian Ethical Office (PlataformaBrasil: http://aplicacao.saude.gov.br/plataformabrasil) under number: 94.121/2012. All participants, or their parents/guardians (for minors aged <18 years), provided written informed consent before study entry.
We selected six state capitals located in four endemic regions in Brazil: (1) Midwest: Goiania/Goias State, (2) Southeast: Belo Horizonte/Minas Gerais State and Rio de Janeiro/Rio de Janeiro State, (3) Northeast: Teresina/Piaui State, Recife/Pernambuco State and (4) North: Belem/Para State (Fig 1). We selected capital cities located in regions of high transmission of dengue infection in the last decade . Capital cities were chosen because they are densely populated areas with the capacity for research development and health staff to perform the fieldwork in a timely manner. We did not include cities in the Southern region as dengue transmission was only concentrated in one area of Parana State.
Fig 1. Map of Brazil: Regions and study sites.
The study population consisted of patients with clinically suspected dengue. Clinically suspected dengue was defined in accordance with the Brazilian dengue guidelines as fever plus two or more of the following manifestations: headache, retro-orbital pain, myalgia, arthralgia, prostration or rash (with or without the presence of hemorrhage) . All sites included children (aged <15 years) and adults. Residents from other municipalities, individuals unable to respond to an interview request, those who refused to give informed consent and those whose residential address could not be located/accessed were excluded from the study. In five of the six sites, the fieldwork was conducted in 2013.The other site, Teresina (Northeast), the fieldwork was conducted during 2012 and 2013.
We estimated a sample size of 300 ambulatory patients and 100 hospitalized patients would be required for each site in the original protocol. This estimate was based on the assumption that these numbers were sufficient to sample patients of all age groups and disease severity, and to have sufficient statistical robustness. A minimum of approximately 30 hospitalized patients were to be recruited at the sites with low virus circulation.
We contacted all patients with clinically suspected dengue or their care-givers so as to interview them with regard to their illness. Interviews with the patients or their care-givers were planned for two phases.
ambulatory and hospitalized cases (ambulatory cases were defined those cases who attended healthcare facilities, and hospitalized as those cases who required an hospital stay of 24 hours or more). This screening interview was undertaken to recruit patients or their care-givers, to explain project objectives, to obtain informed consent, to collect baseline information and schedule household interviews. We arranged the household interview 15–20 days after the onset of clinical symptoms.
Cases identified during phase 1 or their care-givers were interviewed using a questionnaire (described below) after resolution of their symptoms. Field-workers performed the interviews using Tablet devices and entered the answers directly whenever possible.
We adopted a questionnaire for use during interviews with the patients or their care-givers identified, which was developed in a previous multi-country cost study , to collect resource use data in public and private ambulatory clinics and hospitals (see S1 Text). This questionnaire helped document: the characteristics of the dengue episode; history of previous dengue illness; date of initial appearance of symptoms/signs and their resolution; use of medical services(medical visits; medications, laboratory exams); work and school absences; household spending (out-of-pocket expenses); and income lost (loss of productivity). We augmented the questionnaire used in the previous study by adding questions about medication use, whether dengue was laboratory confirmed, and about laboratory tests and x-ray examinations undertaken. A pilot study was conducted to evaluate the feasibility of the questionnaire and the field strategy before the full investigation. In addition to the interviews, we extracted data from the patients' medical records for those who were hospitalized to gather resource use information (hospital stay, laboratory/exam and medication). The information collected regarding resource is subject for an accompanying paper.
We used the ABEP classification (Criterio de Classificacao Economica Brasil, CCEB 2012, available at www.abep.org) to determine the economic level of the patients or their care-givers. This classification estimates the purchasing power of individuals and families. This index is equivalent to the mean family income per month with 8 economic classes as follows: top level of income [A1 (US$ 5,698); A2 (US$ 3,711)]; mid-level income [B1 (US$ 1,947); B2 (US$ 1,131)]; low-level income [C1 (US$ 679); C2 (US$ 451)]; very low-level income [D (US$ 315) to E (US$210)].
According to the SINAN database, there were 2,013,274 suspected dengue cases reported between September 2012 and August 2013 (Table 1). The majority of these reported dengue cases were aged 15 years or older (approximately 1.7 million cases), of which, more than 50% of cases were in females. The majority (99.5%) of the reported cases were classified as "classical" dengue, 0.5% were classified as severe dengue cases (dengue with complications, dengue hemorrhagic fever and dengue shock syndrome). All four dengue serotypes co-circulated in Brazil, with serotype 1 and serotype 4 being the main serotypes detected during the study period. There were 569 deaths due to dengue disease reported in SINAN. Dengue epidemics were reported in two of the study regions during our investigations: the Southeast and Midwest neighboring regions with the cities of Belo Horizonte and Goiania registering dengue incidence rates ≥50 per 1,000 inhabitants (Table 1). The official definition of dengue epidemic by the national surveillance system is when the number of cases exceeds the number of cases of the upper limit relative to the incidence represented by diagram of control in a specific region . It should be noted that SINAN is a passive surveillance system and it is likely that the number of cases would have been under-reported, particularly for non-hospitalized cases, as is the tendency with such surveillance systems .
Table 1. Dengue epidemiology in Brazil overall, and by site in the four regions (surveillance data from the Brazilian national notifiable diseases information system [SINAN] September 2012 to August 2013).
The Brazilian health system consists of a complex public-private mix healthcare delivery/utilization and financing system . The public sector comprises the Unified Health System (Sistema Unico de Saude—SUS) and is considered to be a universal system (open to all) funded by the government. Citizens have the right to receive preventive measures and treatment, free of charge under this system. The private sector offers health service by direct payment and/or covered by health insurance plans (Unimed; Plamta, MedPlan, Cassi and others). The participation of the private sector in the Brazilian health system is classified as "setor suplementar"/supplementary care .
We used a micro-costing, bottom-up approach. The costs of ambulatory or hospitalized cases were calculated as the average cost of each component of direct and indirect cost as shown in S1 and S2 Tables. All costs were initially calculated in the local currency (Real) and converted to US dollars (US$) using an average exchange rate (R$ 1 = US$ 0.44079 on November 20, 2013) by OANDA (www.oanda.com).
The cost for a medical visit for an ambulatory case in the public sector included the SUS value for one medical visit to the emergency department (US$ 4.85) . The inclusion of a medical visit to the emergency department, which is the highest price paid by SUS, was done because the current cost of an ambulatory visit was considered to be undervalued . In the private sector, the unit cost for each medical visit funded from a health insurance plan was taken from the Unimed plan (US$ 26.45) since this was the insurer used by the majority of the study population . The direct cost of hospitalized patients included the cost of hospitalization (hospital stay) and the cost of ambulatory care for those who sought ambulatory treatment before inpatient hospitalization. We calculated the percentage of hospitalized patients who received previous ambulatory care in each city and added these costs to the hospital costs. For both medication (http://portal.anvisa.gov.br) and laboratory tests (http://sigtap.datasus.gov.br) the public sector costs were taken from Brazilian Government data. Private sector medication costs were taken from Guia Farmaceutico Brasindice (January, 2013) and laboratory tests from the Associacao Medica Brasileira (http://www.amb.org.br/_arquivos/_downloads/cbhpm_2012.pdf).
We estimated the loss in productivity due to illness and death. The value of lost productivity due to illness took into account the number of work days lost by patients or caregivers during the course of illness. We also included the number of days of school missed by patients (see S1 and S2 Tables). The number of work days lost or school days missed were derived from the household interviews. Loss of income by patient or care-giver was based on the perceived the monetary value of the previous month's income. The value of lost school or college days took into account the level of education in each state and was based on the annual cost per student of US$ 6,612.00 (http://www.jusbrasil.com.br/diarios/DOU/2012/11/19 and http://ultimosegundo.ig.com.br/educacao/educacao+basica+custa+mais+na+particular+superior+na+publica/n1597000724462.html).
Data analyses were undertaken using SPSS 17.0, Microsoft Excel 2010 and Package R (accessed at: http://www.r-project.org/). The unit of analysis was a dengue episode, defined as a symptomatic dengue case with or without laboratory confirmation. We analyzed the patients with dengue by sites, stratified by whether they were ambulatory and hospitalized, in both public and private facilities. We carried out exploratory analysis for continuous variables to evaluate the distribution patterns and outliers. For skewed distributions, we used a non-parametric test (Kruskal Wallis test) to compare the number of days in hospital between sites.
Descriptive statistics, frequencies, means and standard deviation (SD) were calculated to compare costs across sites. We used the chi-square test to compare the distribution of the characteristics of dengue cases between sites and we used residual analysis to identify the significant heterogeneities among sites. The Tamhane post-hoc test was applied for multiple comparative analyses of means with non-homogenous variances. We opted to perform this first analytic approach using means and standard deviations (SD) as recommended for cost analyses .
To calculate the overall national cost we used the number of cases reported in Brazil and the number of cases reported in the six cities studied during the period (SINAN data). We adopted the ratio of ambulatory:hospital (9:1) as a parameter to estimate the number of ambulatory and hospitalized cases at the national level (Siqueira personal communication, 2013). We assumed that 65% of patients attended the public sector in the Southeast and Midwest regions and 75% in the North and Northeast regions . The estimated cost per case was calculated as: the total amount of direct and indirect costs from the dengue episodes calculated in each of the six cities (primary data) divided by the number of estimated cases in the six cities of the study. We estimated the overall national cost by multiplying the estimated cost per case by the estimated number of ambulatory and hospitalized cases notified in Brazil between September 2012 and August 2013 (see S2 Text).
In our study, five deaths occurred during the study period, all at one site (Belo Horizonte). We estimated the cost of fatal cases at national level using the human capital approach to determine the cost associated with the loss of productivity from these cases . We estimated the cost of fatal dengue as the lost income from premature death . Based on the number of deaths in SINAN database (2011, 2012 and 2013), we estimated the average age at death due to dengue to be 45 years for males and 42 years for females. We calculated the years of life lost and used a standard discount rate of 3% per year. We estimated the remaining life labor expectancy at their age of death considering the minimum age of retirement for males of 65 years and 60 years for males and females, respectively. We multiplied the average discounted years by Brazil gross domestic product (GDP) per capita in 2012 (US$ 10,420.70).
We applied a probabilistic sensitivity analysis to our data using RiskAMP software (Structured Data LLC 2005). We investigated how variations of ± 50% (min; max) affected the best estimate derived from our data by computing 10,000 Monte Carlo simulations. We used a beta-PERT distribution and reported the results in terms of certainty level (CL) bounds using 10 and 90 percentiles. We varied the mean values obtained by the field study (direct cost per case, total cost per case) and then estimated the annual costs of dengue at national level by ambulatory and hospital in both public payer and societal perspectives. Simulation of expansion factors took into account higher variability: EF used for ambulatory cases were 1.5; 3; and 6. We assumed the variation (1; 1.6; 2) for the EF for hospitalized cases. In the latter the simulation includes the EF = 1.6 cited in the literature .
The estimated cost of dengue in Brazil was considered from two perspectives: public payer and societal. The public payer perspective included only direct costs in the public healthcare setting (medical visits, medications and laboratory/examinations). The societal perspective included direct and indirect costs, weighted by public and private sectors. Two scenarios were evaluated for each perspective (public payer and societal) as a sensitivity analysis to capture some of the uncertainty in the number of cases reported in SINAN. In the first scenario (base case), we used official registered dengue cases by SINAN to estimate the cost of dengue in Brazil (as described above). In the second scenario, we applied EFs yielded from sensitivity analysis: for ambulatory cases (EF = 3.2) and for hospitalized cases (EF = 1.6) in order to adjust for underreporting . We have also extrapolated the dengue burden using temporal series from 2009 to 2013 (SINAN online database). We assumed the same parameters as described above.
Of the 2,223 patients that were screened for dengue, 2,035 (91.5%) symptomatic dengue patients were included in our study (Fig 2). Patients were excluded if they did not provide signed informed consent or if their residential address could not be located/accessed. The number of dengue cases recruited ranged from 279 in the Southeast and North (Rio de Janeiro and Belem) to 415 in the Northeast (Teresina) (Table 2). Approximately 80% of the cases were ambulatory. The difference in the percentage of hospitalized cases between sites was statistically significant (X2 = 94.3; df = 5, p<0.001). The residual analysis showed that the proportions of hospitalized patients were similar in the Northeast and North regions (Teresina: 14.5%; Recife: 12.8%; Belem: 18.3%); the highest proportions were found in Goiania (29.5%) and Belo Horizonte (23.3%) (Table 2).
Fig 2. Flowchart of the study design.
Table 2. Characteristics of suspected dengue cases recruited by site in the four regions in Brazil.
Overall, the adult population (≥ 15 years) constituted around 80% of recruited cases. The proportion of dengue cases in the adult population by site ranged from 64.6% in Recife to 87.1% in Rio de Janeiro. There was a significant difference in the proportion of dengue cases in the adult population reported between all sites (X2 = 65.4; df = 5, p<0.001). All sites recruited a similar proportion of dengue cases in the age group 0–14 years, except Recife where higher percentage of children and adolescents (35.4%) were recruited (X2 = 3.5; df = 5, p = 0.6). The female:male ratio per site was about 3:2(Table 2).
The cost per ambulatory and hospital dengue case across the four regions, from the societal perspective, stratified by public and private sector and by site are summarized in Table 3. Direct costs for ambulatory cases varied from US$ 31 (Rio de Janeiro) to US$89 (Belo Horizonte) in the public sector and constituted the lower share of the total costs for each site except Belo Horizonte. In the private sector, the direct costs varied from US$ 77 (Recife) to US$168 (Goiania). Results from the Anova and Kruskall-Wallis tests (<0.05) showed significant differences between cities in terms of costs per ambulatory dengue case. For ambulatory patients in the public sector two similar subgroups were identified, one group with lower costs (Belem, Teresina and Rio de Janeiro) and the other the higher cost (Belo Horizonte and Goiania), based on the Tamhane post-hoc test. The city of Recife was associated with both subgroups with P value <10%.
Table 3. Cost per ambulatory and hospitalized dengue case across four regions in Brazil, societal perspective (2013 US$).
The total cost for hospitalized patients in the public sector varied from US$238(SD 70) in Belem to US$479 (SD 336) in Belo Horizonte. In the private sector, the total cost varied from US$ 318 (SD 164) in Belem to US$ 1,577 (SD 1,572) in Recife. Direct costs constituted the higher share of the total costs for hospitalized cases in both public and private sectors, except for Recife. Two main subgroups of cities were identified according to direct costs for hospitalized dengue patients in the public sector: the lowest direct cost were calculated for three sites (Belem, Teresina and Recife), and highest direct cost for two sites (Belo Horizonte and Goiania), according to the Tamhane post-hoc test.
Fig 3 shows the highly-skewed cost data reported for the ambulatory and hospital cohorts stratified by public or private sector. The majority (approximately 80%) of the ambulatory cases treated in the public sector incurred costs of less than US$ 220 per dengue episode. Costs associated with ambulatory cases treated in the private sector were also skewed: few patients had costs higher than US$ 440. For the hospitalized cohort, more than 80% of the dengue episodes cost US$440 or less in the public sector.
Fig 3. Cost distribution of dengue episode by type of care and health sector (2013 US$).
The higher incidence of dengue during the study period was observed in the Southeast and Midwest region of the country, with more than 50 cases for every 1,000 inhabitants (Table 1). The estimated costs of dengue in Brazil presented in Table 4 took into account the uneven distribution of cases between regions as well as differences in dengue management costs. The adjusted direct costs (observed costs weighted by the number of reported cases for each site (see S2 Text) of a dengue episode for ambulatory and hospitalized cases was US$ 64 (90% CL: 48–80) and US$ 237 (90% CL: 177–297), respectively. Extrapolating our estimates to national surveillance system data, we estimated the annual total cost for dengue at US$ 164 million (90% CL: 123–205) from the public payer perspective. This figure increases to an estimated US$ 447 million (90% CL: 335–559) when we adjusted for underreporting (EF = 3.2 for ambulatory cases and EF = 1.6 for hospitalized cases). From the societal perspective, we estimated the annual total cost for dengue at US$ 404 million (90% CL: 301–508) or US$ 1,147 million (90% CL: 885–1,445), the latter figure also estimated with EFs for possible under-reporting (Table 4). These annual total estimated cost for dengue correspond to per capita costs of US$ 6.7or US$ 19.0 (with EFs) from the societal perspective based on the labor force population (60.2 million, IBGE 2011). In Brazil, there were an average 529 deaths due to dengue and an average of 944,733 notified dengue cases (SINAN, 2011–2013), with a fatality rate of 0.056% (90% CL: 0.051–0.061). At the national level, the total cost for fatal a dengue episode was approximately US$ 65 million (90% CL: 48–81); US$ 34 million for males and US$ 31 million for females. We estimated the cost of a fatal dengue case as US$ 122,477.41 (Table 4).
Table 4. Estimated costs of dengue in Brazil from the public payer and societal perspectives, considering two scenarios (2013 US$).
Fig 4 shows the reported dengue cases and the burden of dengue from 2009 to 2013. In this five years period, the reported dengue cases was the lowest (409 thousand cases) in the year 2009, increased to more than 1 million cases in the epidemic year of 2010 and reached 1.4 million in the year 2013. Therefore, the total costs depends upon the number of reported dengue cases and deaths, varied from US$ 371 million (2009) up to US$ 1,228 million (2013).
Fig 4. Estimated cost of dengue by reported number of cases in the period 2009–2013 (2013 US$).
The cost of dengue was estimated considering the ratio of ambulatory:hospital (9:1). These costs do not include the cost of vector control neither the cost of the surveillance system. Estimated number of reported dengue cases were based on online surveillance data (SINAN, 2009–2013), with EFs.
Our study is the first multi-center study to assess the cost of dengue illness across four dengue-endemic Brazilian regions, taking into account ambulatory and hospitalized cases in both the public and private sectors. The total economic burden of dengue in Brazil from a societal perspective was estimated at US$ 468 million (90% CL: 349–590) (with no adjustment for underreporting), of which, the majority (67%) was associated with ambulatory cases. Indirect costs (i.e. lost productivity) constituted the higher share of the total costs for ambulatory cases in both public and private sectors, consistent with a previous cost evaluation of the economic burden of dengue episodes in Brazil . Moreover, higher total costs for ambulatory cases were observed in wealthier regions in our study which might have been due to, for example, more laboratory tests and lost productivity. From the public payer perspective, the total economic burden was estimated at US$ 164 million (90% CL: 123–205 million) (with no adjustment for underreporting).
We adopted a similar protocol to a previous cost evaluation of the economic burden of dengue episodes in Brazil, which included the city of Goiania, as part of an international cost of dengue study that included five countries in the Americas [9, 10]. However, the previous study applied unit cost for health services using only private sector values . Therefore, the costs per case for ambulatory and hospitalized cases were higher in the earlier study compared to our results. Our data clearly show higher costs in the private sector compared to the public sector for both ambulatory and hospitalized cases. However, the estimates for the public sector ambulatory visit may be conservative even when applying the highest value of the medical visit reimbursed by the Unified Health System (SUS).
Our study is at least, in part, consistent with a recent retrospective cross-sectional census study by Vieira Machado et al (2014) on hospitalized dengue patients in the public and private Brazilian health sectors in Dourados City, Mato Grosso do Sul State . The latter study reported direct mean medical costs per hospitalized dengue case in the public sector of US$ 510 (SD, 1,135) (values adjusted for inflation for the year 2013), compared with US$ 198–376 in our study. Vieira Machado et al also reported higher mean direct medical cost of US$ 1,193 (SD, 2,701) (values adjusted for inflation for the year 2013) per hospitalized dengue case in the private sector relative to the public sector, compared with US$ 318–906 in our study. Of note, their study was based on a sample of 288 laboratory-confirmed dengue cases, whereas our study was based on a much broader case definition that included 2,035 suspected dengue cases. In addition, we recruited cases from different geographic areas in Brazil from the study conducted by Vieira Machado et al.
The current economic evaluation was conducted concurrently with major dengue outbreaks in the Southeast and Midwest regions (Belo Horizonte and Goiania), in the period August 2012 September 2013. Approximately 100,000 probable dengue cases were registered in the city of Belo Horizonte in the Southeast region and about 56,000 cases in Goiania in the Midwest region. However, there was a decrease in the incidence of dengue cases and hospitalizations reported in the city of Rio de Janeiro compared to previous years. In addition, the cities of Belem (North), Recife and Teresina (Northeast) had a reduction in both incidence and hospitalizations for dengue. As such, we evaluated the economic burden in areas that included both dengue outbreaks and low virus circulation. This approach, including settings with high and low virus transmission, is recommended by the dengue guidelines for cost evaluation .
Our study has both strengths and weaknesses that need to be considered when making generalizations for the whole of Brazil. A strength of our economic burden study is that we included several types of health facilities in both private and public sectors across four dengue-endemic regions in Brazil in order to provide more representative cost estimates of the population assessed. Moreover, the cases recruited to our study had a similar gender and age distribution across the regions, and were in line with data obtained in the official notification system for Brazil, suggesting that they were representative of the population in those regions. They also had similar income level distributions to the general population in their region according to census data. Another strength was that we designed our study in line with current guideline recommendations .
The main limitation of our study is that the total cost depends largely on number of dengue cases registered in the passive surveillance system in Brazil (SINAN). Other drawbacks of using passive surveillance systems in economic burden studies include: selection bias; data may not be well suited for economic study; data gathered for other purposes; and inherent underlying confounding factors. Nonetheless, passive surveillance systems are a readily available source of data that is representative of the national sample of suspected dengue cases and as such, maximizes external validity. It is also well known, that the number of symptomatic dengue cases and its geographical location, like most vector-borne disease, varies each year. As such, the ambulatory:hospitalized ratio would vary according to the burden of the disease during dengue outbreaks or periods of low virus transmission rates. The ambulatory:hospitalized case ratio could also be affected by the implementation of temporary health structures (tents or stabilization wards) during outbreaks, as observed in Belo Horizonte in 2013 .
In addition, our study focused on the economic burden of dengue in urbanized areas of Brazil, and as such, may not be extrapolated to less-urbanized areas. The cost estimates obtained in our study pertain to a one year study period and outbreaks were reported in some specific capital cities. There was no concerted effort to estimate the costs associated with dengue outbreaks in this study. To fully cost dengue outbreaks, we would have needed to account for the various stages of the outbreaks—before, during and after an outbreak. For indirect costs we estimated only the loss of income of patients who perceived had a monetary income in the previous month. For example, if the dengue patient was a housekeeper and did not perceive a monetary income, their illness would still present an economic loss to the economy but would likely not have been captured in our analysis and thus would have led to an underestimation of indirect costs. Finally, it was beyond the scope of the present study to include cost components related to preventive strategies such as vector control, routine activities, recurrent costs, and operational costs, as well as the cost components related to outbreak control, community mobilization and tourism.
To place the cost estimates of the epidemic year (in the current study) in temporal perspective, we also estimated the global costs of dengue for cases registered in the five years up to 2013. The historical series of dengue cases reported provides an example of the large annual variation in the number of registered cases, and whether they can be considered epidemic or endemic years. Our results underscore the need for regular national cost evaluation, preferably alongside the surveillance system. However, the under-reporting or the over-reporting of dengue cases by the surveillance system are constant issues raised in the literature and by policy makers. We opted to estimate the cost of dengue for suspected cases instead of the laboratory-confirmed cases in accordance with current guidelines for cost estimates of costs .
In Brazil, there has been a decrease in age-standardized incidence and deaths from malaria in the last decade. Around 130,000 malaria cases and 71 associated deaths were registered in the 2013 . In contrast, there has been a striking increase in dengue in the last decade with over 1 million cases and over 500 deaths registered in the 2013. Of note, dengue transmission has now reached most of the regions in the country but malaria is currently restricted to the Amazon basin region . The comparison of the cost of dengue with other infectious disease in Brazil is hampered since there are few cost studies of epidemic diseases nationwide.
In summary, our study shows that the economic burden associated with dengue in Brazil is substantial. We hope our study will help policy makers to inform their decisions when setting goals and priorities, and assessing estimates of the impact of any proposed interventions in the management of dengue. We believe that our results are a timely estimate of the cost of a dengue episode in Brazil, considering both the public payers and the societal perspective.
S1 Table. Data sources used to calculate direct and indirect costs for ambulatory dengue cases.
S2 Table. Data sources used to calculate direct and indirect costs for hospitalized dengue cases.
S2 Text. Assumptions to estimate cost per dengue case using primary data from six cities and extrapolating to national level.
We would like to acknowledge Dr. Donald S. Shepard and Dr. Jose A. Suaya for their helpful comments. We also thank the anonymous reviewers for their comments during the evaluation process of the manuscript. Editorial assistance with the preparation of this manuscript was provided by Richard Glover, inScience Communications, Springer Healthcare.
Conceived and designed the experiments: CMTM JBSJ WVdS NTdSF. Performed the experiments: MPPDP ALdSAZ CSO CB FGPJ FC LRB MCOM MQMdR. Analyzed the data: CMTM JBSJ MPPDP ALdSAZ FC JGL NTdSF DC WVdS. Contributed reagents/materials/analysis tools: CMTM JBSJ MPPDP ALdSAZ FC JGL NTdSF DC WVdS. Wrote the paper: CMTM JBSJ MPPDP ALdSAZ CSO CB FGPJ FC JGL LRB MCOM MQMdR NTdSF DC WVdS.
1. World Health Organization. Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control. 2009. Available from: http://www.who.int/tdr/publications/training-guideline-publications/dengue-diagnosis-treatment/en/. Accessed 9 September 2014.
2. World Health Organization. Global strategy for dengue prevention and control 2012–2020. 2012. Available from: http://www.who.int/denguecontrol/9789241504034/en/.Accessed 9 September 2014.
4. Cafferata ML, Bardach A, Rey-Ares L, Alcaraz A, Cormick Gea. Dengue epidemiology and burden of disease in Latin America and the Caribbean: a systematic review of the literature and meta-analysis. Value Health Reg Issues. 2013;2:347–56.
7. Brasil. Ministerio da Saude. Secretaria de Vigilância em Saude.Departamento de Analise de Situacao em saúde. Saude Brasil 2012: Uma analise de situação de saúde e dos 40 anos do Programa Nacional de Imunizacoes. Capitulo 6 Doencas com Potencial Epidemico no Brasil 2000 a 2009–2013- Brasilia: Editora do Ministerio da Saude, 2013.189–211.
8. Suaya JA, Shepard DS, Beatty M. Dengue burden of disease and cost of illness. WHO Scientific Working Group: Report on Dengue Vol. TDR/SWG/08 (2006). Available from: www.who.int/tdr/publications/documents/swg_dengue_2.pdf. Accessed 9 September 2014.
12. Armien B, Arredondo J, Carabali M, Carrasquilla G, Castro R, Durand L, et al. Costing dengue cases and outbreaks: a guide to current practices and procedures. 2012. Available from: http://www.jhsph.edu/research/centers-and-institutes/ivac/projects/costing-dengue-cases-outbreaks-guidelines.pdf. Accessed 9 September 2014.
21. Ministry of Health (Brazil). Dengue: diagnosis and clinical handling. Available from: http://portal.saude.govbr/portal/arquivos/pdf/. Accessed 9 September 2014.
22. Secretaria de vigilancia em saude, Ministerio da Saude. Diretrizes nacionais para a prevencao e controle de epidemia de dengue. Brasil. 2009.
24. IBGE. Censodemografico 2010. Available from: http://www.ibge.gov.br/home/estatistica/populacao/censo2010/default.shtm. Accessed 9 September 2014.
25. Instituto Brasileiro de Geografia e Estatistica. Pesquisa Mensal de Emprego, 2013. IBGE. 2013:32.
26. Ministerio da Saude (Brasil). SIGTAP—Sistema de Gerenciamento da Tabela de Procedimentos, Medicamentos e OPM do SUS. Available from: http://sigtap.datasus.gov.br/tabela-unificada/app/sec/procedimento/exibir/0301060096/05/2013. Accessed 9 September 2014.
27. Carvalho DMT. Financiamento da assistencia medico-hospitalar no Brazil. Cien Saude Colet. 2007;12:879–92.
28. UNIMED. 2013. Available from: http://www.unimed.coop.br/pct/indexjsp?cd_canal=49146&cd_secao=49125&cd_materia=338815. Accessed 9 September 2014.
29. Drummond MF, Sculpher MJ, Torrance GW, et al. Methods for the economic evaluation of health care programmes. New York, Oxford Medical Publications. 2005.
30. Sculpher M. The role and estimation of productivity costs in economic evaluation. In: Drummond M, McGuire A, editors. Economic evaluation in health care Merging theory with practice Oxford University Press 2001:94–112.
31. Butchart A, Brown D, Khanh-Huynh A, Corso P, Florquin N, Muggah R. Manual for estimating the economic costs of injuries due to interpersonal and self-directed violence. Available from: http://whqlibdoc.who.int/publications/2008/9789241596367_eng.pdf. Accessed 27 July 2015.
34. Prefeitura Municipal de Belo Horizonte. PORTARIA SMSA/ SUS-BH No 0010/ 2013. Autoriza o funcionamento em regime de plantão nas Unidades do SUS. Diário Oficial do Município Ano XIX Edição 4279.


This is the first of a minimal few that I've started on for … ta da! The Incredibly Challenging Third Album!
Really, I have one album out on iTunes, Amazon et-ceter-ah, and one on Bandcamp, and where should I bung this ICTA? Maybe I'll try the new SoundCloud Pro which promises full distribution and all that.
Makes little difference, but I do like bunging my stuff Out There occasionally. My teenage self would be very proud, aaah.
Anyway, enjoy that one, and keep checking for more tracks!
New Album – MoleSkyneChyno – only released on Bandcamp! Not available anywhere else, even not on YouTube! Available to buy from Bandcamp, or just listen, that's very fine too. Enjoy!
So – the Difficult Second Album gets a title – MoleSkyneChyno – and a nice picture from Valerie Taylor.
If the above Bandcamp player thing isn't showing above then go to https://chintzbaby.bandcamp.com/album/moleskynechyno on Bandcamp itself.
This lot took a while, uses only open-source music software and no samples wot-so-ever. No samples! So it will sound very different from my first properly released album A Curation of Curious Creatures.
I've decided to only release it on Bandcamp (where lots of your friends will be buying it) because it really can be a right old faff to do a proper release on other media. I'm interested to see what Bandcamp will do with it too. They seem to be up there with yer iTunes, Amazon et al.
It's fun to see the Bandcamp timings are different from mine own!
Out! Now! A Curation of Curious Creatures! Woooeee!
A Curation… is an experiment in using stock things – stock sound loops from Apple, a stock black cat via Pixabay and stock video loops from Ignite Motion, all royalty free. All except Magenta Mole, which exclusively uses one ZynAddSubFX synth.
All composition is ChintzBaby's, which is the best bit.
Thanks to : Apple, IgniteMotion, Mark McCurry, Harald Hvaal (ZynAddSubFX), Mike Monday, Gerhard Lengeling and Chris Adam (eMagic Logic original developers) and Dan Dennedy (ShotCut). None of whom knows me.
Lovely cat from : OpenClipart-Vectors.
… hence the title of the album. I do think, and I would, that there's something for everyone in this Curation, so have a listen – best place to start is my previous blog post with it all on YouTube.
Pre-order on Amazon – A Curation of Curious Creatures!
More to be said about it soonish, so checkout the links on my about page and see what it's all about.
CheersO, must dash, too excited to write more, I expect I'll get used to that … ha!
A Curation … is an experiment in using stock things – stock sound loops from Apple, a stock black cat via Pixabay and stock video loops from Ignite Motion, all royalty free. All except Magenta Mole, which exclusively uses one ZynAddSubFX synth.
I really must get my videos up on Vimeo and YouTube – megabytes of them all, could take a while. Probably longer than it took to make them.
5th May 2017 – new album out !
I've joined the PRS, which is a bit of an ambition of mine (it's easy to join if you have a hundred quid, but best if you have something for them to collect royalties on, yey!).
And, for another hundred quid or so I've paid for distribution to all the usual places – Amazon, iTunes, Spotify etc etc, so you won't be able to move without seeing it somewhere. Oh, and I have a barcode to play with too – so exciting!
So – what's the Album called then? You'll have to wait and see!


The UNS team of Security Certified Product Specialists assess, develop, and implement solutions that optimize your network security.
No matter the size of your business or what level of network security your company has, we will assess and implement the best solution to keep your business cyber safe. If the needs and size of your business require staff augmentation, UNS can help there too. We offer contract, contract-to-hire, and permanent placement staffing globally. We are dedicated to providing clients with the most experienced and qualified talent to ensure all technology needs are met.
In the world of ever-changing threats to your network security, let our team of trained consultants ensure that you all touch points of your network are secure. Our consultants are will ensure that all programs are installed correctly, functioning properly, trained effectively, and sustained optimally. All of this will provide assurance that your business's security needs are being met.
We offer a full range of security services on all of the products we install.
The landscape for network security is changing, and it is important that your security solutions are both comprehensive and adaptable.
With more applications and information stored in the cloud, it is important that these things are still protected while remaining accessible. UNS builds security solutions to ensure that your information is protected and available.
To stay ahead of potential cyber attackers, UNS works with the leading product vendors to implement innovative and robust security solutions.
UNS will analyze the current state of your business's IT security plan and how to best protect your business from online threats. We work together with our clients to assess current and future IT needs and develop implementation programs from there.
Our team will ensure that security extends to all endpoints and that all devices comply with the criteria our consultants require before network access is allowed.
Implementing endpoint protection plans is something our consultants are trained to do. From protecting against malware to anticipating threats at each endpoint, our team will implement a comprehensive protection plant that provides broad coverage.
Detecting threats at the earliest possible moment is critical when your sensitive data is at risk.
Unfortunately, all too often, threats go undetected in networks.
Our network security consultants help you reduce risk and better understand the full scope of any threat they detect. No longer will the lack of expertise or threat intelligence be obstacles to your network security.
UNS will work as an extension of your network security team.
Our team of Network Security Consultants will monitor your environment 24x7, provide early warning of cybersecurity threats and arm you with the actionable insights you need to quickly respond.
Health Check: We will do a quarterly health check of each system and look at the basic performance of the system to ensure efficient throughput, making certain it is functioning at its maximum potential.
Log Review: At specified intervals, we will review system logs to check for proper performance (false positives etc), security issues, and any other items of concern.
Dashboard Setup: We will set up and customize a viewable dashboard that will provide performance statistics at a glance for managers and/or system administrators.
Dashboard Monitoring: We will review dashboard statistics for trends and anomalies.
Reporting: We will generate periodic management-level summary reports detailing any trends, items of interest, customer specified information and anomalies.
System Administration: UNS will perform system administration tasks on the system we monitor. This includes system refinement, as well as rules and updates based on information acquired during monitoring.
UNS consultants will train your IT staff on all programs installed by our team.
On-site or web-based training options available.
UNS training sessions equip your IT staff with the necessary skills to manage your network security solutions and make sure you are maximizing the coverage of your comprehensive network security strategy.
UNS partners with McAfee to provide your business with protection against malware and other online risks.
UNS will also help ensure your enterprise has cohesive, top-down control in adhering to mandated government regulations, risk management and the compliance with those regulations.


text:
class DisplayScene : public cocos2d::Layer
{
private:

public:
    virtual void show();
    virtual void hide();
    static cocos2d::Scene* createScene();
    virtual bool init();
    void exit(cocos2d::Ref* pSender);
    CREATE_FUNC(DisplayScene);
};

#endif

redpajama_set_name: RedPajamaGithub


text:
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Is Streaming Killing Big Screen Films?
Steaming is devastating for people who want to make films for the big screen, says Dame Helen Mirren.
19:29 19 April 2018
Categories : Tv streaming
Dame Helen Mirren has said that the rise of watching films on streaming services, such as Netflix, is killing the communal experience of cinema.
The award-winning actress, who is married to Director Taylor Hackford, said: "It's devastating for people like my husband, film directors, because they want their movies to be watched in a cinema with a group of people,"
"An audience, a movie, and you're all in it together," she said. "You're frightened, you laugh, you cry all together. So it's a communal thing. And that's beginning to disappear."
However, recent figures have suggested that despite the rise of streaming services, the attraction of the cinema is not waning. Last year, UK cinemagoers spent a record of £1.38billion on tickets, which represents a 6.1per cent increase on the previous year.
Meanwhile, Netflix films have been banned from this year's Cannes Film Festival, which has decided that starting this year, all films in competition must have a cinema release.
Next: 5G to Revolutionise Streaming in UK
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AgraME is the largest trade exhibition dedicated to the agriculture, aquaculture, poultry, livestock and veterinary industries within the region.
With over 220 exhibitors from all corners of the world, this event is the ideal opportunity to view innovative products within the industry. Sectors include agriculture and irrigation, animal husbandry and poultry farming, floriculture and horticulture, fisheries, pesticides, chemicals, aquaculture and agricultural machinery sectors.
AgraME boasts a multitude of industry-leading exhibitors under one roof. Attend seminars, conferences and business networking sessions regarding the latest technologies and practices within the industry.
Last year, the three-day event hosted companies and organisations such as Al Dahra Agicultural L.L.C., FRAmelco, IFFCO, the Ministry of Environment and Water, and Royal Brinkman to name a few, with over 87% of attendees regarding AgraME as crucial to the success of their marketing activities in the Middle East.


In 1981, the Ohio Historical Society organized the Ohio Village Muffins to show how recreation and base ball were becoming a part of life in the mid-nineteenth century. The team was the first in the nation to play a regular schedule of vintage base ball matches and the Society has assisted in the formation of nearly 50 other vintage teams in Ohio and beyond, including Colorado, New York, Georgia, and Canada.
In 1996 the Muffins hosted the founding meeting of the Vintage Base Ball Association to further the historical interpretation of the game. The Muffins play in uniforms patterned after the Currier and Ives lithograph The American National Game, on display at the Ohio Historical Center. The uniforms consist of plain long pants, a white shirt with a bright shield containing the team emblem, a pill box hat, a leather belt with the team name embossed on it, and a bow tie.
The name "Muffin" originates from the organization of 1860s gentlemen's base ball clubs. The best squad was known as the "first nine," the second-string players were the "second nine," and those not well skilled were the "muffin nine," a muff being the term for an error.
The pieces of equipment used by both the Diamonds and the Muffins are reproductions. Bats are no bigger than 2.5 inches in diameter, but may be of any length. Balls are 10 inches in circumference with a single piece of leather covering them. Bases are at least one square foot and are filled with sand or sawdust. Ball gloves and protective equipment had not been invented.
On November 23, 1993 an organizational meeting was held at the Ohio Historical Center to form a ladies base ball team. At the meeting many names were suggested for the club among them: Lady Birds, Daisies, College Ladies, Cardinals and Diamonds. Accounts show that ladies enjoyed watching base ball, but playing the game was frowned upon by …society. In order to play and get some exercise, ladies were known to go into the back fields and play their own games of base ball. These ladies became known as "Diamonds in the Rough", and thus, Diamonds were chosen as the team name. Two volunteers were then selected to head up the team, Dianna Frias and Pam Koons. The uniforms were made by Dorothy Brandon and were dark blue with black trim.
The newly named Diamonds received publicity as the first team to re-create early women's base ball. The Diamonds first officially took the field as part of a co-ed match at Kenyon College on Sunday May 1, 1994. The first Diamond match in Ohio Village was played against a group known as the Ohio Village Daisy Cutters. The Muffin Tin of May 31, 1994 records that the Diamonds won the game 3-1.
Finding opponents to play was a major problem for those early Diamond clubs. Many times, simple demonstrations were scheduled in place of actual matches. In 1996, the Diamonds abandoned their early uniforms for the simple dresses of the1860 time period and better represented the ladies playing in the back fields from which their name derived. More importantly, another ladies club had been formed in Sycamore, Ohio called the Crickets, later re-named the Katydids. The following year a third club formed at Carriage Hill Farms in the Lady Clodbusters.
The breakout year for the Diamonds came in 1998 with an increasing number of new volunteers joining returning veteran players. Also the number of ladies clubs in Ohio grew to four with the addition of the Akron Lady Locks.
The teams became good friends and often joined together to form an Ohio team as they traveled around the country playing in tournaments. Besides Ohio, the Diamonds have played in Pennsylvania, New York, Michigan and Minnesota. Unfortunately, by 2008 both the Katydids and the Lady Locks had dissolved, leaving only the Lady Clodbusters and Diamonds in the state. Today, the Diamonds gain extra games by playing exhibition games against local teams at festivals around Ohio.
The pioneering spirit and grit of those first Lady Diamonds has brought about the current success of the club and helped spread the history of the great game of base ball.
Currently, 18 players are on the roster. While many of their games are on the road, they play every year at the Ohio Cup and still call the Ohio Village home base.


StarCityGames.com - Core Set 2019 Commander Review!
Core Set 2019 Commander Review!
Elder Dragons are back and coming to a Commander table near you! Not only does Core Set 2019 give you new versions of iconic favorites, it also provides some new additional fuel for your Commander engines.
Remember that this is a review for Commander only. There are plenty of individual cards, especially at the common and uncommon slots, which will be houses in other formats. Not including them here isn't an indictment of any kind of the card, just recognition that it's not a great fit for the format. I'll break everything down by color, pick some winners for the color, and then give it an overall grade. Let's jump right in.
Aethershield Artificer: Sure, you don't want Solemn Simulacrum to be indestructible, but there are plenty of other things that you want to keep from dying. Even Wurmcoil Engine might be really nice to keep perpetually alive.
Ajani, Adversary of Tyrants: The low mana cost makes this Ajani quite playable and quite capable of getting to that emblem. I can't see too many situations that lead to using the -2 ability, but remember there's always Phantom Nishoba. Or Saffi Eriksdottir.
Cleansing Nova: Excellent choice of modes make cleansing Nova worth the extra mana, although it still doesn't have the flexibility of Austere Command. There's no reason you can't play both as part of your board-sweeping suite. Creatures can regenerate from Cleansing Nova, but it's not like there are lots of regenerators running around anyway.
Lena, Selfless Champion: This one seems a little schizophrenic, since most token decks want to buff them up. Of course, if you're buffing with Cathar's Crusade, Lena gets bigger too, so all is well.
Leonin Warleader: A fine addition to any Cat deck, since it makes more Cats every time you battle, which is what you're always doing with them anyway.
Mentor of the Meek: Obviously a reprint, but worth calling out because it's a bit of an underplayed card.
Remorseful Cleric: Graveyard hate is getting better and better. I don't want to jinx what that might mean for some cards.
Resplendent Angel: Power creep is real, as there was a time you'd never find a three mana, three power flying white creature, let alone one that has two other relevant abilities. Many Angel decks have no trouble gaining five life, sometimes every turn. This is going into my Trostani deck, and I predict hijinx.
Suncleanser: Sweet design space. There are so many creatures in Commander that love counters, from Kresh, the Bloodbraided to Blood Tyrant to Ghave, Guru of Spores, that the sun will frequently get cleansed. The other great use for this will be to remove age counters from a card with Cumulative Upkeep. As far as removing counters from a player, there's the obvious making-of-friends with poison counters, but also remember that the player gets the experience counters from Ezuri, Claw of Progress and friends; removing them might just keep you alive.
Valiant Knight: I'm already keen on making a Knight deck and then some sweet ones came out in Dominaria, like Arvad the Cursed and Aryel, Knight of Windgrace (and commanders getting double strike is always saucy). Now Valiant Knight to go along with Knight Exemplar, and we're in business. I think I have a new project.
Favorites: Resplendent Angel and Valiant Knight.
Grade: C+. Good, not great, with nothing that makes me want to run around and be crazy, and a modest number of playable cards (which is of course due to the reprints, so it's not like I'm counting that as a sin).
Djinn of Wishes: A reprint that deserves a little more love than it gets.
Metamorphic Alteration: So you start with your nice utility creature, like Mulldrifter, and then turn it into something immense after it's done its work. Another nice slice of design space.
Mistcaller: Tokens are a strategy in Commander, and Mistcaller will sometimes make that strategy not happen.
Mystic Archaeologist: At first glance it doesn't seem that great, but then you realize that it doesn't tap to use its ability. It's still a little expensive, but if the baseline for drawing a card with no downsides is four mana, then the flexibility makes it worth it.
One With the Machine: Previous cards like this have tended to be targeted, so you could get really screwed if the target were removed. Here, even if the big thing gets blown up, you still get something.
Patient Rebuilding: Mill decks love the card already without the card draw. Once that gets stapled on, you don't even have to be all that patient in your rebuilding.
Psychic Corrosion: Cards that do something you want done when do you other things that you are already doing at no mana are deceptively strong. Note that it's each opponent and every time you draw a card. I'm imagining some scenario in which two players who both have Consecrated Sphinx decide that they can mill out the other players.
Sai, Master Thopterist: There is much goodness to this card, but I have to confess that Thopters makes me think of the bees episode of Black Mirror , which is the one that actually scared me.
Tezzeret, Artifice Master: You know you're nearly always drawing two cards with that +0 ability. Getting to the emblem will be a little tougher, although I suppose you could use those Thopters to protect Tezzeret. And again, the bees.
Windreader Sphinx: It's a reprint from the Magic 2014 Core Set, but I think it needs a little more love. You get to draw a card whenever any creature with flying attacks, whether or not you're involved in the combat. Super sweet and will pay for itself in no time.
Grade: B-. As with white with a few saucier cards.
Abnormal Endurance: My kind of card, the +2/+0 is not significant; saving your best creature for only two mana, however, is right in my wheelhouse.
Bone Dragon: Longtime readers will know that I'm not a fan of exiling things from my own graveyard, but I might go as far as getting one use out of Bone Dragon. Might.
Demon of Catastrophes: Oh, the heady days when Demons were bad for you. In 2018, we have 6/6 trampling fliers for four mana. I have an "old school" Demons deck, and this one wouldn't go in it. In something like Karador, Ghost Chieftain, however, this Demon is not catastrophic at all.
Epicure of Blood: Not that many commons see play in Commander, but this will be one of them, giving players another element in the Exquisite Blood combo.
Fraying Omnipotence: I'm not really sure the format needed a bigger version of Pox, but there's also an argument that super-high life totals need to be combatted with something other than commander damage. Of course, Fraying Omnipotence goes right into your Thraximundar deck.
Infernal Reckoning: On first blush, it might be easy to dismiss Infernal Reckoning, but then we remember that Commander is full of Eldrazi, such as Ulamog, the Infinite Gyre and Kozilek, Butcher of Truth, that need to get exiled so that their abilities can't trigger. I'm not big on one-for-ones in Commander, but the fact that you gain life from the creature's power makes it better than a straight up trade.
Isareth the Awakener: I'm going to try to use Isareth in a deck to get around my dislike of exiling my own cards. I'm not promising (emotional) success, but we'll see.
Liliana, Touched by Death: This Liliana is pretty much limited to your Zombie decks, but the fact that you can use her last ability right away is quite something.
Liliana's Contract: Showing her diversity, Liliana moves from Zombies to Demons with aplomb. Even if it doesn't win the game for you, it's a good addition to your Demon deck due to the card draw. The "draw cards/lose life" signature is quite prevalent in the black cards in the set.
Open the Graves: Quite useful for a deck (like the aforementioned Karador) which likes to move creatures in and out of the graveyard, there's also the simple value to Open the Graves of helping you recover from a big board wipe. You won't be protected against the next one, but it's still good enough for me.
Grade: B. We're improving in small steps as we go.
Alpine Moon: A fair way to shut down lands that can get abusive, like Cabal Coffers or Nykthos, Shrine to Nyx.
Apex of Power: Apex indeed. This is such a representative card of Commander that there should be a picture of Timmy on it. Sure, you need the ten mana to cast it, but then you basically get your choice of casting one or more of the next seven for free. Yes, you're limited by the fact that you only get one color of mana, but that's hardly a downside.
Demanding Dragon: A card that will definitely see Standard play, it's not likely to see much action in Commander outside of a few tribal decks.
Doublecast: It is, of course, no Fork, since it's not an instant and you can only copy your own spells, but it's a nice tool in red's kit for dealing big piles of damage for only two mana instead of twice whatever you'll have pumped into that X spell.
Goblin Trashmaster: You probably don't need all that many Goblins to make the Trashmaster quite useful-and we all know that there are going to be more Goblins running around than you know what to do with. Also, a nice bit of retribution for someone else's Blasphemous Act.
Lathliss, Dragon Queen: Simply put, your Dragon deck just got an order of magnitude better-as if they weren't already dealing out death and destruction. The pump ability seems a little unnecessary and a bit of an afterthought.
Sarkhan, Fireblood: Cool art. Meh card.
Sarkhan's Unsealing: Wait, what? Clearly six and seven power is a strong demarcation, but still-repeatable board wipes for your opponents when you're doing the thing that you came to do? Awesome.
Tectonic Rift: Obv play is to destroy Maze of Ith.
Thud: Okay, the name is a little cheesy and it's not an instant like Fling, but it also only costs one mana.
Favorites: Apex of Power, Lathliss, Sarkhan's Unsealing, Thud.
Grade: A-. The cool stuff is pretty cool, but the rest of the color doesn't play out that well.
Colossal Majesty: Hey! I like having creatures with power four or greater! I also like drawing cards. Majestic.
Elvish Clancaller: It's not calling much of the clan, since it doesn't do anything in Commander besides buff up your other Elves. What would be cool is if you're also playing Wheel of Sun and Moon, activated Elvish Clancaller's ability, then respond by sacrificing it to do something strong. Then it'll be in the library when you resolve the ability-but honestly, six mana is a lot for just a neat trick.
Elvish Rejuvenator: Interesting take on ramp in that it will occasionally whiff (I suspect less often than you might think), but it gets more than basic lands. For me, that makes it playable.
Ghastbark Twins: The option to block two creatures would be better if it weren't a 7/7 trampler that doesn't have vigilance.
Gigantosaurus: I can hear it now: "But it doesn't have evasion!" It's a 10/10 for five mana. You'll be able to spend what you saved on some method of getting around the problem.
Hungering Hydra: X mana creatures can sometimes be awkward (like when they get blinked), so this one only gets consideration because of the triggered ability. Pro play: with Aether Flash on the battlefield, cast this for X => 3.
Pelakka Wurm: Just giddily happy to see this old favorite in a Core Set.
Runic Armasaur: Another card that I think some folks will gloss over, Runic Armasaur is going to draw you way more cards than its mana cost would suggest.
Scapeshift: I'd be interested in hearing why the development team wanted to put this in the set. I'm not complaining, I'm just curious.
Vine Mare: Cool flavorful design, although I don't suspect we'll see it in too many Commander decks.
Vivien Reid: Vivien will be all about the long trek to getting that emblem. The +1 ability is fine; the -3 will be pretty useful in desperate situations, but having indestructible creatures that are bigger and more tramply is a thing of beauty.
Vivien's Invocation: I love the Timmyness of this set. Seven mana is quite a bit to pay, but you'll only play this in your deck if you fill it with creatures which are worth finding. You put the creature onto the battlefield as opposed to casting it without paying the mana cost. This might be significant if you find an Eldrazi with a cast trigger, which won't go off.
Favorites: Colossal Majesty, Elvish Rejuvenator, Runic Armasaur, Vivien Reid.
Grade: B. The cool stuff is every bit as good as red's, but the rest of the color is worse.
Arcades, the Strategist: The return of the Elder Dragons in younger (and less upkeep-y) form excites me a great deal. We've probably already picked out our next Rotisserie Draft theme. The smallest of them all, Arcades is akin to Doran, the Siege Tower, in that they can have powerful effects, but your deck becomes quite dependent on its commander. We old school players immediately thought of Wall of Blossoms to go with this version of Arcades.
Chromium, the Mutable: In one of the triumphs of flavorful design in all of Magic history, you have to get quite creative in order to make the activated ability useful. I suppose that giving it hexproof keeps you from having to cast it again, but there aren't too many situations in which I want to turn my flying 7/7 into a 1/1 unless it's getting targeted by removal or theft. Sure, when the Dragon hunters come around, it has a need to be able to hide among them, but the ability seems like only an emergency measure. That emergency measure can have an upside, which is getting that card which you'd prefer to have in the graveyard instead of your hand actually into the graveyard.
Nicol Bolas, the Ravager: Inexpensive mana cost is only the first step of the multiverse's greatest villain's latest incarnation. At the low cost, the discard might even be relevant. The more expensive thing is transforming it into Nicol Bolas, the Arisen, which is completely bonkers. Drawing two cards for zero mana will excite the most stoic player. The ten damage probably isn't relevant in Commander, but it might occasionally be. The reanimation, which I'll point out is from any graveyard, is super-relevant. The ultimate, of course, is just a wrecking ball for someone. I think my preferred plan is to use the +2 until I'm at eleven loyalty counters, then use the -4 just to 1) let folks know that I'm not going to use the ultimate, and 2) hey, free stuff.
Palladia-Mors, the Ruiner: Mostly misnamed, because it doesn't really ruin very much besides life totals. Even then, its only a 6/6, not a 7/7. Okay, it ruins life totals pretty well, given the flying, vigilance, and trample. It doesn't thematically bring anything to a deck, so I might end up just making it one of 99 somewhere.
Poison Tip Archer: You know how good Blood Artist is? Poison Tip Archer is better. For one, it has other relevant abilities. Reach plus deathtouch will keep lots of scary things from crashing into you. Two, it's all opponents instead of targeting just one.
Regal Bloodlord: If this had been a Vampire Knight (see Valiant Knight, above), it would have been cooler.
Satyr Enchanter: Enchantress decks get another tool for their kit.
Vaevictus Asmadi, the Dire: They saved the best for (alphabetically) last. I'm in Jund heaven. There's some play in this card, because you have to do proper threat assessment-plus, you choose yourself as well. Polymorphing that utility creature like Solemn Simulacrum into something huge is all full of win. Lategame, you're probably turning a land into a creature for yourself while taking out relevant permanents of your opponents.
Grade: A. Elder. Dragon. Legends.
Amulet of Safekeeping: I've heard this called the enemy of storm, which we don't really see that much in Commander. Also making those Plant tokens off of Avenger of Zendikar a little smaller is fine by me, although that -1 probably doesn't matter much when Craterhoof Behemoth comes along.
Arcane Encyclopedia: Remember when I said the baseline for drawing cards with no downside is four mana? Turns out it's now three.
Chaos Wand: A fun and harmless toy until Paradox Engine comes along and ruins it for everyone. Also, a beating for the player with a heavy creature deck which doesn't contain too many instants or sorceries. What I mean to say is that I'm getting occasionally wrecked by this card.
Desecrated Tomb: Excellent design space, although I'm not sure of its usefulness. If your 30 creature graveyard gets eaten by a Bojuka Bog, you still only get one Bat, not a swarm.
Dragon's Hoard: I think I'll still prefer my three-cost, any-color-of-mana artifact to be indestructible, but this variation on a theme has its uses in your Dragon deck. There will be a point at which you don't need the mana boost, so drawing cards for free is great. Kudos for the design of a card which is differently useful at various stages of the game.
Sigiled Sword Valeron: The mana and equip costs are appropriate to the value that you get. Vigilance is often a life-saving ability.
Suspicious Bookcase: Put the candle back .
Transmogrifying Wand: Only costing one mana to activate might make Transmogrifying Wand playable. There are lots of huge creatures in Commander, and turning them into 2/4s isn't all that bad.
Grade: Unfair to grade because there simply aren't that many cards in the subsection.
We'll give Core Set 2019 an overall B on a pretty harsh grading curve. By its very design and intentional appeal to the Core Set audience of less experienced players, we knew going in that it would have fewer cards which resonated with Commander players-meaning a B might be the best it could hope for. Nonetheless, there are enough new toys to keep most Commander players happy between now and the date that we're all really waiting for: August 10-and the release of Commander 2018.
Deck Without Comment will return after release season.
Purple Hippos and Maro Sorcerers ; Kresh Into the Red Zone ; Halloween with Karador ; Dreaming of Intet ; You Did This to Yourself .
Heliod, God of Enchantments ; Thassa, God of Merfolk ; Erebos and the Halls Of The Dead ; Forge of Purphoros ; Nylea of the Woodland Realm ; Karn Evil No. 9.
Lavinia Blinks ; Obzedat, Ghost Killer ; Aurelia Goes to War ; Trostani and Her Angels ; Lazav, Shapeshifting Mastermind ; Zegana and a Dice Bag ; Rakdos Reimagined ; Glissa, Glissa ; Ruric Thar and His Beastly Fight Club ; Gisa and Geralf Together Forever .
Adun's Toolbox ; Angry, Angry Dinos ; Animar's Swarm ; Borrowing Stuff at Cutlass Point ; Ikra and Kydele ; Karrthus, Who Rains Fire From The Sky ; Demons of Kaalia ; Merieke's Esper Dragons ; Nath of the Value Leaf ; Rith's Tokens ; The Mill-Meoplasm ; The Altar of Thraximundar ; The Threat of Yasova ; Zombies of Tresserhorn .
Yidris: Money for Nothing, Cards for Free ; Saskia Unyielding ; Breya Reshaped ; Yidris Rotisserie Draft Deck .
Tana and Kydele ; Kynaios and Tiro ; Ikra and Kydele .
Adun Oakenshield Do-Over ; Animar Do-Over ; Glissa Do-Over ; Karador Do-Over ; Karador Version 3 ; Karrthus Do-Over ; Kresh Do-Over ; Steam-Powered Merieke Do-Over; Lord of Tresserhorn Do-Over ; Mimeoplasm Do-Over ; Phelddagrif Do-Over ; Rith Do-Over ; Ruhan Do-Over .
The GAM Podcast: Core Set 2019 Top 10s!


Diabetes is a chronic disease that involves the regulation of blood sugar and occurs in two different forms, type 1 and type 2.
Type 1 diabetes usually develops in children or young adults, but can start at any age.
Type 2 diabetes is a metabolic disorder resulting from the body's inability to produce enough, or to properly use, insulin.
Causes of hypoglycemia in children with diabetes may include a missed meal, too much medication, or more exercise than usual.
During adolescence, blood sugar levels become harder to control, resulting in levels that swing from too low to too high.
Having a child with diabetes can be overwhelming. Fortunately, a team of experts can guide you now and in the years to come.
When fall arrives, it's back-to-school time—and for some kids, it's back to dealing with diabetes in the classroom.


Ask a business owner what they want from their brand they'll typically tell you that they want to be different; to stand apart from the competition and capture the attention of clients.
But when it comes to, say, selecting a new brand identity from three different creative routes, most business owners will opt for the slightly safer option. Can I blame them? Not really. Being different in your marketplace can be lonely. It's uncomfortable and edgy and it takes sustained effort and confidence to pull off.
It's why fruit juice labels look the same, why every perfume ad reeks of unoriginality and why tech companies all look and sound like tech companies.
Scratch that. Not 'all'. Almost all.
The breakthrough brands are the ones that look, sound or feel different. When Innocent launched their range of smoothies and juices, they could have easily opted for an illustration of sun-drenched (yet dewy) citrus fruit.
Similarly, humour was out of bounds for estate agents before Purple Bricks came along. And when Tyrrells started out, crisp packet design was all about the ingredients and not definitely not quirky vintage photography.
As I say, being different is uncomfortable; edgy.
And yet, the audacity and bravery of this single branding decision helped create a company that was sold 14 years later for £300 million.
That sort of stratospheric success is what most business owners crave. After all, market leadership is where it's at. But to achieve it takes brave, bold, creative branding. And it follows that middle-of-the-road marketing delivers middle-of-the-road results.
Plus, as every business owner knows, brands need to work harder than ever before if they are to even stand still.
Today's consumers are bombarded with messaging, marketing and conversations. They are used to filtering out brain-jolting amounts of information from any and every channel, and to focussing on just the results they're interested in or looking for. Everything else becomes white noise.
To reach these audiences takes verve and creativity – and that goes for both B2B and B2C markets. After all, the people making the buying decisions in both sectors are ultimately… people. And while these 'people' enjoy the comfort of the familiar, they respond much more keenly to the quirky or creative.
Accountants don't have to be blue. Fast food restaurants don't have to be red. You get the idea.
If you can say what you need to say on your website homepage in 200 words, there's absolutely no need to stretch it out to 500. Remember your readers and they will thank you for it.
You know what a premium food brand should look like, right? Probably something like Tesco Finest? Sumptuous photography, black background, serif font? Hmmm. Why should they look like that, exactly?
If you would like to find out more about how a dash of creativity can transform your business, get in touch with me at SIM7 (sim@sim7creative.co.uk).
I promise I won't suggest a logo featuring a flamingo on a burning tyre.