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University Microfilms International 300 N INFORMATION TO USERS This was produced from a copy of a document sent to us for microfilming. While the most advanced technological means to photograph and reproduce this document have been used, the quality is heavily dependent upon the quality of the material submitted. The following explanation of techniques is provided to help you understand markings or notations which may appear on this reproduction. 1.The sign or “target" for pages apparently lacking from the document photographed is “Missing Page(s)". If it was possible to obtain the missing page(s) or section, they are spliced into the film along with adjacent pages. This may have necessitated cutting through an image and duplicating adjacent pages to assure you of complete continuity. 2. When an image on the film is obliterated with a round black mark it is an Indication that the film inspector noticed either blurred copy because of movement during exposure, or duplicate copy. Unless we meant to delete copyrighted materials that should not have been filmed, you will find a good image of the page in the adjacent frame. 3. When a map, drawing or chart, etc., is part of the material being photo* graphed the photographer has followed a definite method in “sectioning" the material. It is customary to begin filming at the upper left hand comer of a large sheet and to continue from left to right in equal sections with small overlaps. If necessary, sectioning is continued again—beginning below the first row and continuing on until complete. 4. For any illustrations that cannot be reproduced satisfactorily by xerography, photographic prints can be purchased at additional cost and tipped into your xerographic copy. Requests can be made to our Dissertations Customer Services Department. 5. Some pages in any document may have indistinct print. In all cases we have filmed the best available copy. University Microfilms International 300 N. ZEEB HOAD. ANN ARBOR. Ml 48106 18 BEDFORD ROW. LONDON WC1R 4EJ, ENGLAND 8115125 K r a m e r , M a r k A l a n C0ST-EFFEC11VENESS OF SCREENING, CONTACT TRACING. AND VACCINATION AS ALTERNATIVE GONORRHEA CONTROL STRATEGIES USING A COMPUTER SIMULATION MODEL The Ohio State University PH.D. 1981 University Microfilms International300 N .Z eeb Road. Ann A lte r, M l 48106 PLEASE NOTE: In all cases this material has been filmed In the best possible way from the available copy. Problems encountered with this document have been Identified here with a check mark V . 1. Glossy photographs or pages______ 2. Colored Illustrations, paper or print_____ 3. Photographs with dark background ______ 4. Illustrations are poor copy______ 5. Pages with black marks, not original copy______ 6. Print shows through as there is text on both sides of page______ 7. Indistinct, broken or small print on several pages ***" 8. Print exceeds margin requirements______ 9. Tightly bound copy with print lost In spine_____ 10. 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Other_______________________________________________________ ___________ University Microfilms International COST-EFFECTIVENESS OF SCREENING, CONTACT TRACING, AND VACCINATION AS ALTERNATIVE GONORRHEA CONTROL STRATEGIES USING A COMPUTER SIMULATION MODEL DISSERTATION Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy In the Graduate School of The Ohio State University By Mark Alan Kramer, B.S., M.S., M.S. a a a a a The Ohio State University 1980 Reading Committee Approved By Professor Richard Lanese (Adviser) Professor Thomas Chlrikos Professor Winslow Bashe Adviser Department of Preventive Medicine ACKNOWLEDGEMENTS I am indebted to Dr. Paul Wiesner and Dr. Gladys Reynolds of the Venereal Disease Control Division, Center for Disease Control, Atlanta, Georgia for providing me with the opportunity to work on this research. 1 would like to thank Dr. Robert Johnson also of the Venereal Disease Control Division for his enormous contributions in helping me work through problems encountered in the model's formula­ tion and analysis. I am appreciative of Dr. Winslow Bashe for his valuable epidemiological insights as well as his willingness to com­ mute long distances to serve on my committee. I am greatly Indebted to Dr. Thomas Chirikos without whom I could not have conceptualized the theory and application of cost-effectlveness analysis and the health system in general. My greatest appreciation goes to Dr. Richard Lanese who has been not only my mentor, but a good friend and advocate for ten years. If I had not had Dr. Lanese's continu­ ous support, it would have been difficult for me to complete the rigorous tasks required for this degree. I cannot possibly thank my mother, Ronnie Sanders, enough for her support and for the outstanding job she did in typing this dis­ sertation and its drafts, and also my father, Dr. Arthur Kramer, for his emotional support. Finally I would like to dedicate this work to my wife, Tobie, and my children, Rebecca and Benjamin, and thank them for their sacrifices, encouragement, and love throughout the duration of this research. ii VITA February 3t 1952 ........ Born - Cleveland, Ohio 1973 ........... Columbus, Ohio 1973-1974 . Operations Research, Case Western Reserve University, Cleveland, Ohio 1974 ........... Cleveland, Ohio 1974-1976....... Laboratory, The Ohio State University Columbus, Ohio 1976-1978....... Columbus Health Department Columbus, Ohio 1978 ........... Columbus, Ohio 1978-Present ........... Mathematical Statistician, Venereal Disease Control Division, Centers for Disease Control, Atlanta, Georgia PUBLICATIONS "Characteristics of Defaulters In Treatment for Infection with Neisseria Gonorrhoeae." J. Infect. Pis, 140: 649-651, 1979. "Incidence of Scabies in White and Black Populations," Arch. Dermatol. 115: 1286, 1979. "Self-reported Behavior Patterns of Patients Attending a Sexually Transmitted Disease Clinic," Am. J. Public Health 70: 997-1000, 1980. ill "Gonorrhea In Che Emergency Department: Management Case Follow-up and Contact Tracing of Cases In Women." Am. J. Obstet. Gynecol. 138: 1105-1108, 1980. FIELDS OF STUDY Major Field: Preventive Medicine Studies in BiostatiBtics. Professor Richard Lanese Studies in the Health System. Professor Thomas Chlrlkos Studies in Epidemiology. Professors Winslow Bashe and Martin Keller Studies in Environmental Health. Professor Harold Elllngson iv TABLE OF CONTENTS Page ACKNOWLEDGEMENTS.......................................... 11 VITA.................................................... ill LIST OF TABLES.......................................... vii LIST OF FIGURES.........................................xiv Chapter I. INTRODUCTION.................................. 1 II. GONORRHEA EPIDEMIOLOGY AND CONTROL A. Epidemiology of Gonorrhea............ 6 B. Gonorrhea Control Issues .............. 9 C. Gonorrhea Vaccine and Immunological Issues.............................. 13 III. MODELING THE EFFECTS OF HEALTH PROGRAMS A. The Role of Modeling in Measuring Health E f f e c t s ............................ 26 B. Selection of a Modeling Strategy to Measure Health Effects ................ 36 IV. CONSIDERATION OF VARIABLES AND ESTIMATION OF PARAMETERS A. Variables to Be Considered by the Model. 41' B* Delphi Survey for Parameter Estimation . 45 C. Estimation of Parameters............. 49 V. THE GONOVACS MODEL A. Assumptions of the Model ............. 68 B. Procedural Logic of the GONOVACS Model . 73 C. Output Measures of the GONOVACS Model. 82 D. Technical Considerations .............. 86 E. Validation and Verification of the Model . 91 v Chapter Page VI. SIMULATION RUNS A. Sensitivity Analysis ................... 93 B. Screening Programs ......... ...... 93 C. Contact Tracing Programs ............... 94 D. Vac cine-A Programs................... 96 E. Vaccine-B Programs .................... 97 VII. RESULTS A. Sensitivity Analysis ................... 98 B. Screening Programs.................. 103 C. Contact Tracing Programs ............... 108 D. Vaccine-A Programs..................... 116 E. Vacclne-B Programs .................... 122 F. Cost-Effectivenees of Programs ......... 126 VIII. DISCUSSION A. Overview............................... 143 B. Value of the Model in Improving the State of the Art ......... 145 C. Evidence for Validity of Model ........... 147 D. Sensitivity Analysis ............. 152 E. Screening Programs .................... 156 F. Contact Tracing Programs ......... 159 G. Vaccination Programs.................... 164 H. Comparison of Alternative Control Programs ............................. 170 I. Future Directions for the Model........... 175 J. Potential for Simulation in Health Services Research........................177 •IX. S U M M A R Y ......................................... 179 LIST OF REFERENCES........................................ 182 APPENDICES A. Gonorrhea Vaccine Simulation Model Questionnaire.................* ............ 190 B. Probable Characteristics of Gonorrhea in the Natural State......................... 194 C. Cost Estimates............................... 197 D. Estimates for Impact of Contact Tracing Programs.....................................199 E. Estimates for Impact of Screening Programs. 202 F. Tables from Results ........ 204 G. Listing of GONOVACS Program .................. 303 vi LIST OF TABLES Table Page
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