Bunyavirales. We isolated the virus by cell culture assay. BJNV could induce cytopathic effects in the baby hamster kidney and human hepatocellular carcinoma cells. Negative-stain electron microscopy revealed enveloped and spherical viral particles, morphologically similar to those of nairoviruses. We identified 67 patients as BJNV infection in 2017–2018. The median age of patients was 48 years (interquartile range 41–53 years); the median incubation period was 7 days (interquartile range 3–12 days). Most patients were men (70%), and a few (10%) had underlying diseases. Common symptoms of infected patients included fever (100%), headache (99%), depression (63%), coma (63%), and fatigue (54%), myalgia or arthralgia (45%); two (3%) patients became critically ill and one died. BJNV could cause growth retardation, viremia and histopathological changes in infected suckling mice. BJNV was also detected in sheep, cattle, and multiple tick species. These findings demonstrated that the newly discovered nairo-like virus may be associated with a febrile illness, with the potential vectors of ticks and reservoirs of sheep and cattle, highlighting its public health significance and necessity of further investigation in the tick-endemic areas worldwide.Several nairo-like viruses have been discovered in ticks in recent years, but their relevance to public health remains unknown. Here, we found a patient who had a history of tick bite and suffered from a febrile illness was infected with a previously discovered RNA virus, Beiji nairovirus (BJNV), in the nairo-like virus group of the order  Bunyavirales [Ticks rank only second to mosquitoes as arthropod vectors of animal and human pathogens, including viruses, bacteria, and parasites , 2. Overavirales . HoweverMonitoring unexplained fever cases in a sentinel hospital is an effective method to identify disease-related pathogens, by which many new tick-borne viruses associated with human diseases, such as severe fever with thrombocytopenia syndrome virus, Alongshan virus (ALSV), and Songling virus (SGLV), have been identified in China . Active The cohort study recruited patients who reported being bitten from ticks in the General Forestry Hospital of Inner Mongolia in 2017–2018, whose blood specimens were collected. The sample size relied on the case number in the hospital during the period. We used a standardized questionnaire to collect data on demography, medical history, and tick exposure of each patient. We obtained the clinical symptoms and laboratory tests from the electronic medical records. We showed these data as they were, without any imputation for the missing data. The patients who were tested positive for viral RNA were included in this study, and the patients who co-infected with other pathogens were excluded. One hundred healthy people who were not bitten from ticks were used as controls; they were matched with the patients in gender and age.g for 10 min within 24 h of collection and stored at −80°C until use. Ticks were sampled using flagging vegetation in northeast China in May, 2015, and identified to species by analysis of the morphological traits and 16S ribosomal RNA (rRNA) gene as described previously [The animal blood samples were collected from sheep and cattle in Hulunbuir, Yakeshi, Inner Mongolia in 2017. Sera were isolated by centrifugation at 1000 eviously , 13.g for 30 min at 4°C, and the supernatants were sequentially filtered through 0.45 and 0.22 µm filters, followed by extraction of viral RNAs. Total RNAs were used for reverse transcription with random primers (5′-GCCGGAGCTCTGCAGATATCNNNNNN-3′), followed by synthesis of double-stranded cDNA (dscDNA) using a Klenow fragment. Sequence-independent single-primer amplification was used for amplification of the dscDNA, and the PCR products were purified and sequenced in the Beijing Genome Institute .Viral metagenomics was conducted as described previously , 14. BriAfrican green monkey kidney (Vero), baby hamster kidney (BHK-21), and human hepatocellular carcinoma (SMMC-7721) cells were used for virus isolation. They were grown in DMEM (Dulbecco’s modified eagle medium) supplemented with 10% fetal bovine serum (FBS), 1 mg/mL streptomycin and 1000 units/ml penicillin and antibiotics.g for 15 min at 4°C. The supernatants were diluted 10 times in DMEM and inoculated onto the confluent monolayer of BHK-21, Vero, and SMMC-7721 cells, respectively. The cells were cultured at 37°C in 5% carbon dioxide, and observed daily for potential viral cytopathic effects (CPE). Three blinded passages of a four-day interval were conducted. The cultural supernatants and pellets were collected to test for the presence of BJNV by a nested RT–PCR. Virus was quantified using fluorescent focus assay, and calculated as fluorescent focus units (FFU) per mL [The blood specimens from patient in the acute stage were centrifuged at 12,000 ) per mL .2, 5 pmol of each primer, 1 μL cDNA 0.5 mM dNTP, and 0.1 μL ExTaq Enzyme (Takara). The 25 μL second-round PCR mixture was the same as the first-round PCR mixture with exception of the primers. Amplification was conducted as follows: 94°C for 8 min followed by 30 cycles at 94°C for 40 s, 52–48°C for 40 s, 72°C for 40–60 s, and a final extension at 72°C for 8 min. The PCR products were purified and sequenced.Total RNAs were extracted from serum or tissue samples by using QIAamp Viral RNA Mini Kit (Qiagen), followed by synthesis of cDNA using the PrimeScript™ RT reagent Kit with gDNA Eraser (TaKaRa). For the nested PCR, the primers targeted on the N gene of BJNV were designed based on the results of viral metagenomics (Table S1). The 25 μL first-round PCR mixture included 2.5 μL 10× PCR reaction buffer, 50 mM MgClFor real-time PCR analysis, the used primers were based on the L gene of BJNV (Table S1). The 20 μL reaction mixture contained 10 μL 2× SYBR premix Ex TaqII (Takara), 0.4 μM of each primer, 1 μL cDNA. Amplification was performed as follows: 95°C for 40 s followed by 50 cycles at 95°C for 8 s, 60°C for 35 s; and 95°C for 20 s, 60°C for 35 s, 95°C for 20 s for melt curve stage.The virus genome was obtained through RT-PCR and rapid-amplification of cDNA ends (Table S2). The PCR products were cloned into pMD18-T vector (Takara) and sequenced using the standard sequencing methods. Phylogenetic analyses were conducted using the maximum likelihood method of the Molecular Evolutionary Genetics Analysis (MEGA).The nucleoprotein gene from BJNV was inserted into pET-30a (Novagen) for prokaryotic expression as described elsewhere . The pur2 FFU of BJNV strain YKS44, and the other group used as control group were administered PBS without virus by the same way. Every five suckling mice were randomly placed in one single cage with their mother, and monitored for 15 days. After administration of BJNV and PBS, the suckling mice that died within 12 h were excluded in statistics. Blood and tissues were collected at indicated time points from euthanized mice for pathological analysis and virus detection. At 15 days post-infection, serum of BJNV-infected mice was collected for virus isolation as described above and quantification of viremia.Wild-type C57BL/6 suckling mice were provided by National Institute for Food and Drug Control, Beijing, China, and maintained at a specific pathogen-free facility. Fifty wild-type C57BL/6 suckling mice  were randomly divided into two groups: one group were inoculated by the intracerebral route with 4.2 × 10The tissue samples, including heart, liver, spleen, lung, kidney, brain, duodenum, and thymus, were collected, fixed in 4% buffered neutral formalin, dehydrated through graded alcohols, embedded in parafﬁn, sliced into pieces (3 μm), and stained with hematoxylin and eosin. Histological changes were observed and captured by a light microscope.t test. The viral infection rates in pooled ticks were determined by maximum likelihood estimation (MLE) in the program PooledInfRate [p-values less than 0.05 were considered significant.We presented continuous measurements as mean (standard deviation or standard error) if they are normally distributed, as median  if they are not, and categorical variables as frequency (percentage). For laboratory results, we also assessed whether the measurements were outside the normal range. We collected the clinical data using Microsoft Excel 2019. All data analyses were conducted with GraphPad Prism software version 5.0 . The differences between different groups were compared using the Student’s dInfRate . Two-wayBabesia, Anaplasma, or Lyme disease spirochetes, were tested negative [In May 2017, a 52-year-old male farmer from Alihe Town of in Inner Mongolia Autonomous Region, China was admitted to the General Forestry Hospital. The patient had a history of tick bite and suffered from a febrile illness with headache seven days after the bite, together with swollen, red, and itchy in bite area. Laboratory tests showed thrombocytosis, leukocytosis and liver function injury in the patient. However, the tick-borne pathogens, such as severe fever with thrombocytopenia syndrome (SFTSV), tick-borne encephalitis virus (TBEV), Alongshan virus (ALSV), negative , 18–20. We isolated the virus from index patient by cell culture assay. Cytopathic effects (CPE) could be observed by 4–5 days after three passages as evidenced by rounded and detached cells in the infected baby hamster kidney (BHK-21) and human hepatocellular carcinoma (SMMC-7721) cells, but not in Vero cells . HoweverNegative-stain electron microscopy revealed enveloped and spherical viral particles, which were similar to the morphology of nairoviruses, with a diameter of approximately 90–100 nm G. Viral Nairoviridae (We obtained the complete genome of BJNV using targeted PCR and rapid amplification of complementary DNA ends (RACE), which included the small (S) and large (L) segments of 3719 and 14,851 nucleotides, respectively A. BJNV soviridae B and 2C.The typical genome of nairovirus is characterized by the terminal reverse complementary sequences (5′-terminus of UCUCAAAGA and 3′-terminus of AGAGUUUCU) [The BJNV L segment contained a 14,436-nt ORF encoding a putative 4811-aa RNA-dependent RNA polymerase (RdRp), which is similar to those of NNV-1 and PTV . In BJNV, the catalytic domain was located between the amino acid residues 2903 and 3451 and contained all known viral RNA polymerase motifs A–E . We also found other motifs of orthonairovirus RdRp in the L segment of BJNV, including the zinc finger, leucine zipper, and ovarian tumour motifs  , 22.The S segment contained a 1659-nt ORF encoding a putative 552-aa nucleocapsid protein (N protein), which is associated with viral RNA synthesis and modulation of host immune responses in bunyaviruses , 24. We During 2017–2018, a total of 658 patients who were bitten by ticks and admitted to hospital were collected and detected for BJNV and other tick-borne pathogens. We identified 129 patients with BJNV infection with complete medical records using real-time RT–PCR, in which 67 were identified only infection with BJNV, and the other 62 were co-infected with other tick-borne pathogens and excluded in the study , showing an IgM positive rate of 62.7% (42/67) and an IgG positive rate of 29.9% (20/67) (Table S8). We further classified all serum specimens into three groups based on the sampling time, showing a higher IgM titer in the 1–10 days group, with a downward trend in the 11–20 days and 21–45 days groups A. An upwIxodes persulcatus (2.0%), Ixodes crenulatus (2.1%), Demacentor silvarum (2.1%), Demacentor nuttalli (0.4%), Haemaphyslis concinna (1.1%), and Haemaphysalis longicornis (0.4%) collected from hilly and wooded regions, with a prevalence ranging from 0.4–2.1% in different tick species (Table S9). A high prevalence of BJNV infection was found in ticks in Inner Mongolia (4.3%) and Jilin (3.3%) as comparison with that in Heilongjiang (1.0%). In addition, BJNV RNA was detected in serum samples that were collected from sheep and cattle in Inner Mongolia, revealing a high prevalence of 54.6% (118/216) in sheep and 37.7% (86/228) in cattle.It is important to note that BJNV RNA was detected by a nested RT-PCR in multiple tick species, including We further obtained partial viral RNA sequences from ticks and domesticated animals by RT-PCR assays, and phylogenetic analysis revealed that they were closely related to those present in human patients , suggesting that they may function the potential vectors and animal reservoirs for this emerging virus, respectively.The most common symptoms of the 67 BJNV-infected patients were fever (67 patients) and headache (66 patients). Other clinical findings included depression (42 patients), coma (42 patients), fatigue (36 patients), myalgia or arthralgia (30 patients), poor appetite (24 patients), and skin rashes or petechiae (21 patients). The clinical symptoms, including cough, chills, chest and/or abdominal pain and tightness, vomiting, lymphadenopathy, diarrhea, nausea, and itching were also observed in some of the patients . Two  of patient had increased level of alanine aminotransferase, 39% (25/65) had increased aspartate aminotransferase, 41% (7/17) had increased lactate dehydrogenase, 15% (3/20) had increased creatine kinase, 8% (5/63) had increased creatinine and 6% (4/63%) had increased serum creatinine. The blood coagulation disorders were also observed in some patients, as shown by elevated levels of activated partial thromboplastin time  and D-dimer  (Table S11).Most patients were treated with a combination of benzylpenicillin sodium and ribavirin. Benzylpenicillin sodium was administered 4 million units per day intramuscularly, and ribavirin was 0.5 g per day intravenously. The symptoms usually disappeared after treatment for 7–14 days. For the critically ill patients, mechanical ventilation was needed immediately when respiratory failure developed.Wild-type C57BL/6 suckling mice were inoculated intracerebrally with BJNV strain YKS44. The infected animals showed significant weight loss at 6, 9, 12, and 15 days post-infection (dpi) as compared to the control group A. ViremiThe present study provided virological, epidemiological, and experimental results of the newly discovered nairo-like virus BJNV, showing that it may be the etiological agent responsible for the febrile illness in northeastern China. BJNV RNA was detected in 67 patients who had the clinical symptoms of fever and headache, while absent in healthy population. The virus has been isolated from the patients, and can infect several human cell lines. The isolated virus could cause disease in suckling mice that produce growth retardation, viremia, and histopathological changes. Re-isolated virus from the infected suckling mice could also induce viremia and histopathological changes in suckling mice.I. persulcatus, I. crenulatus, D. silvarum, D nuttalli, H. concinna, H. longicornis, and domestic animals (sheep and cattle) in northeastern China, while Gakugsa tick virus has been found in I. persulcatus in Russia. Therefore, these ticks may be candidate vectors of BJNV, and the virus may also have a wide geographical distribution.Interestingly, BJNV belongs to a cluster of nairo-like viruses that are genetically closely related to nairoviruses, but seem to be different from the typical nairovirus species, as they are all apparently missing the medium M segment that codes for the viral glycoproteins. More recently, another virus very closely related to BJNV, Gakugsa tick virus, has been described in Russia. This nairo-like cluster consists of possible two other distinct viruses, including South Bay virus found in the United States of America and Grotenhout virus found in Belgium , 6. ReceOur study has limitations. Firstly, we failed to obtain the potential medium segment of BJNV using meta-transcriptomics analysis , as it usually encodes the glycoproteins in the typical nairoviruses. It is possible that the glycoprotein gene of these viruses may be highly divergent, or even non-homologous sequences. Surprisingly, the same phenomenon is also present in some newly discovered species in both phleboviruses (e.g. Tacheng tick virus 1) and chuviruses (e.g. Xīnzhōu nematode virus 5) . HoweverBabesia infection presents with pyretotyposis, splenomegaly, jaundice, or hemolysis etc. Erythema migrans is the early clinical hallmark of Lyme disease, and some patients in advanced stages shows nerve and cardiac abnormalities, musculoskeletal symptoms, or periodic joint damage. However, BJNV infection is not always easy to differentiate from ALSV and SGLV resulting from its similar clinical feature (fevers and headache) in early infecting stages. For now, molecular biotechnology is the best methods to differentiate these viruses  infection. Therefore, more active monitoring patients with BJNV infection to confirm the typical clinical characteristics is urgent and necessary.Ticks can transmit a large number of pathogens to humans, in which most infections may show similar clinical characteristics , 28. TheImportantly, migratory birds can act as long-distance disseminators of ticks and the tick-borne pathogens, suggesting that BJNV may have potential global public health implications , 30. BJNClick here for additional data file.


Despite free diagnosis and treatment for tuberculosis (TB), the costs during treatment impose a significant financial burden on patients and their households. The study sought to identify the determinants for catastrophic costs among patients with drug-sensitive TB (DSTB) and their households in Kenya.n = 1071). Treatment related costs and productivity losses were estimated. Total costs exceeding 20% of household income were defined as catastrophic and used as the outcome. Multivariable Poisson regression analysis was performed to measure the association between selected individual, household and disease characteristics and occurrence of catastrophic costs. A deterministic sensitivity analysis was carried using different thresholds and the significant predictors were explored.The data was collected during the 2017 Kenya national patient cost survey from a nationally representative sample (n = 294). Patients with catastrophic costs had higher median productivity losses, 39 h [interquartile range (IQR): 20–104], and total median costs of USD 567 (IQR: 299–1144). The incidence of catastrophic costs had a dose response with household expenditure. The poorest quintile was 6.2 times [95% confidence intervals (CI): 4.0–9.7] more likely to incur catastrophic costs compared to the richest. The prevalence of catastrophic costs decreased with increasing household expenditure quintiles  from the lowest quintile (Q1) to the highest quintile (Q5). Other determinants included hospitalization: prevalence ratio (PR) = 2.8 (95% CI: 1.8–4.5) and delayed treatment: PR = 1.5 (95% CI: 1.3–1.7). Protective factors included receiving care at a public health facility: PR = 0.8 (95% CI: 0.6–1.0), and a higher body mass index (BMI): PR = 0.97 (95% CI: 0.96–0.98). Pre TB expenditure, hospitalization and BMI were significant predictors in all sensitivity analysis scenarios.The proportion of catastrophic costs among DSTB patients was 27% (There are significant inequities in the occurrence of catastrophic costs. Social protection interventions in addition to existing medical and public health interventions are important to implement for patients most at risk of incurring catastrophic costs.The online version contains supplementary material available at 10.1186/s40249-021-00879-4. Tuberculosis (TB) is a public health concern globally and a major cause of morbidity and mortality . GloballThe World Health Organization (WHO) End TB Strategy aims to end the global TB epidemic . The strIn order to address equitable financial protection for TB patients, there is need to extend coverage of mitigative interventions for patients with TB. The poor and patients with drug resistant TB are more vulnerable to higher costs due to TB , 12, 13.Kenya is one of the top 20 countries contributing to the highest burden of TB, TB/HIV co-infection and DRTB globally . The KenTB services are provided at all levels of the healthcare system. Fifty-eight percent of DSTB patients initiated care at primary healthcare facilities . The refThe National TB Programme (NTP) provides TB diagnosis through sputum examination and anti-TB medicines at no cost to the patient . This exIn 2016, Kenya conducted the first national TB PCS to establish the costs incurred by TB patients and their households, from the onset of TB illness to treatment completion . The surSocial support interventions for TB patients in Kenya exclude those with DSTB. The NTP prioritizes DRTB patients for support through cash transfers and health insurance . This isIn the context of limited resources, there is need to prioritize DSTB patients and households who are most vulnerable to catastrophic costs for targeted interventions. However, given resource constraints, there may be a need for special targeting patients who have DSTB. There is a gap in identifying predictors for catastrophic costs among patients on treatment for DSTB. While, several PCSs have reported the determinants of catastrophic costs for different countries , 24, theKenya is a lower, middle-income country with a population of more than 47 million, of whom 69% reside in rural areas . The couThe first Kenya national patient cost survey was conducted in 2016 . The samThe study design involved a secondary analysis of quantitative data. The data included all DSTB patients (adults and children) collected during the 2016 Kenya national TB PCS in the dataset . The stuThe study outcome variable was the binary presence of catastrophic costs. To determine catastrophic costs, the proportion of annual household expenditure spent on total TB related costs (direct and indirect costs) was calculated. The cost was considered catastrophic when this proportion exceeded the threshold of 20% . OperatiA patient’s perspective was assumed in the estimation of total costs. Direct costs were a total of patient medical costs, patient non-medical costs and guardian and/or treatment supporter costs. Medical costs included consultation fees, payment for laboratory and imaging tests, hospitalization costs and any out-of-pocket (OOP) costs incurred towards purchasing drugs. Non-medical direct costs included OOP payments for travel costs, accommodation costs, food supplements, traditional medicine and costs for services provided by traditional healers. Guardian and treatment supporter costs included OOP payments for transport, accommodation and valuation of time lost. Time lost was valued using the human capital approach by multiplying total hours lost by patient due to the illness or for TB care by the hourly wage calculated from the reported income. The 2017 Kenyan government stipulated minimum wage was adopted when no income was reported. The patient’s valuation of productivity loss was considered as indirect costs .A two-step procedure was used to calculate the costs. First, the two-week estimates reported from the survey were scaled up to estimate the costs and time loss for the treatment phase at the time of the interview. Since patient costs were only available for one phase of treatment, cost for missing phase were then estimated using cost data from the patients in the alternative phase. Costs were extrapolated based on the median costs incurred by the patients in the treatment phase in question at the time of the interview. Hence, the cost and time lost information for those in intensive phase, were used to project intensive phase costs for those interviewed in the continuation phase and vice versa for those in the intensive phase. The mean imputation approach was used to handle missing data .To estimate the annual household expenditure, a consumption approach was used based on self-reported amounts spent on selected goods and services such as food items, non-food items, durable goods and housing . This apRecognizing the inadequacies of data collected during a cross-sectional survey, several assumptions were made in order to determine the costs incurred, productivity losses and household expenditure (Box 2).The exposure variables were selected based on existing literature. Several complex relationships of covariates exist based on previous literature as depicted in Fig. The exposure variables were grouped into three categories: individual, household, and disease and care-seeking characteristics , 33–35. The variables age and BMI were treated as continuous variables for the analysis. Pre-TB household expenditure variable was divided into quintiles in order to demonstrate the dose response relationship between the economic status and catastrophic costs. The mean imputation approach was used for missing variables related to the patient costs .t test and Mann–Whitney test as appropriate. Statistical significance was defined as P < 0.05. The analysis took into account sampling weights used for the Kenya PCS to adjust for clustering effects related to the sampling method  were used. A comparison of patients who incurred catastrophic costs and those without catastrophic costs was conducted using Pearson’s chi square, Fishers test, Student’s g method . Data ang method .CI) were derived from the final model. Similarly, an alpha of < 0.05 was considered statistically significant. Post estimation tests were performed to assess the predictive model. Variance inflation factors (VIF) (below 10) was used to assess for multicollinearity. Goodness of fit using the Pearson’s chi-square test with an alpha of < 0.05 was considered significant to reject the model.Univariable regression analysis was used describe the association between the individual exposure variables and the outcome variable (occurrence of catastrophic costs). We investigated correlations between selected exposure variables. Multivariable regression was then carried out to estimate the adjusted prevalence ratio (PR) as a measure of risk , 38. ThrA deterministic sensitivity analysis was done using different thresholds (10% and 40%) to measure catastrophic costs, and a conservative estimate of the patients’ direct costs (excluding lost income) , 43, 44.A total of 1071 participants were included in the study after excluding 296 patients with DRTB and 130 patients who were ineligible  being children under 15 years. Males formed the majority of the respondents . One out of ten participants had no formal education (n = 127); and a majority had no insurance coverage  , a majority of those hospitalized  incurred catastrophic costs.A comparison of the disease and care-seeking characteristics revealed significant differences for the type of TB, BMI, hospitalization events and the treatment delay Table . The parParticipants incurred a median total cost of USD 270 (IQR: 141–502) from the onset of disease till completion of treatment Table . Non-medParticipants with catastrophic costs incurred significantly higher costs and time losses Table . The totLow household pre-TB expenditure, being hospitalized and having a chest X-Ray examination were associated with a higher prevalence of catastrophic costs. Conversely, a better nutritional status and having pulmonary disease (PTB) was associated with a lower risk of catastrophic costs Table .Table 4UCI: 4.0–9.7) to incur catastrophic costs compared to the wealthiest quintile. Being hospitalized during TB treatment had a PR of 2.8 (95% CI: 1.8–4.5). Treatment delay of more than four weeks was associated with a PR of 1.5 PR (95% CI: 1.3–1.7). Seeking care in a public facility and a higher BMI were protective against incurring catastrophic costs with PR of 0.8 (95% CI: 0.6–1.0) and 0.97 (95% CI: 0.96–0.98) respectively , hospitalization, treatment delay were associated with a higher incidence of catastrophic costs Table . Lower pP < 0.001]. Household expenditure was associated for nutritional status  and having an X-ray . Seeking care at a private hospital was associated with hospitalization .There were significant associations between the covariates Fig. . The typHospitalization, household expenditure and BMI were significant determinants for catastrophic costs in the different scenarios, with changes in the strength of association (PR) Table .Table 5Dn = 582). At 40% threshold however, 13% (n = 137) incurred catastrophic costs and increasing age was an additional predictor. The conservative estimate, using only direct costs had a similar profile for determinants while 21% (n = 224) incurred catastrophic costs.At 10% threshold, 54% of the participants incurred catastrophic costs (Recognizing the determinants of catastrophic costs could provide an insight into approaches for mitigating catastrophic costs among the vulnerable TB patients and their households. This study confirms that a significant proportion of patients with DSTB (27%) incur catastrophic costs, despite free TB diagnosis and treatment. Further, it demonstrates the association between incurring catastrophic costs and poverty, disease severity and delayed treatment initiation. Low economic status is the most significant factor associated with incurring catastrophic costs. Patients who experience catastrophic costs have a lower economic status (pre-TB) and incur higher costs and productivity losses in relation to economic capacity. Patients with severe disease requiring inpatient care, and those who experience delay before treatment are also at a higher risk of incurring catastrophic costs. On the other hand, seeking care at a public health facility and a better nutritional status are protective factors.Being poor prior to TB illness is associated with the highest incidence of catastrophic costs, resulting in the medical poverty trap. Using household expenditure quintiles in this study demonstrates the higher risk associated with the decreasing economic status. This finding is similar to previous studies in other low- and middle-income settings like Uganda , Benin  Malawi  and Chinn = 6), five (83%) of them incurred catastrophic costs. These finding are similar to other studies in Uganda [Although a small number of participants in this study reported having been hospitalized .


Background: As little research has been devoted to examining associations between the four locus-of-hope dimensions  and individual differences, the current study explores the correlations with individual-level individualist and collectivist relational tendencies, self-esteem, insecure attachment, and gender within a culturally diverse sample of university undergraduate students. Methods: questionnaires were completed by a culturally diverse sample of undergraduate students measuring locus-of-hope, individualist and collectivist relational tendencies, self-esteem, insecure attachment, and gender. Results: State and trait locus-of-hope were significantly correlated. Individualism showed positive correlations with internal and external—family locus-of-hope. Collectivism positively correlated with internal locus-of-hope and the three external locus-of-hope dimensions. Internal locus-of-hope was significantly predicted by self-esteem, relational self-esteem, individualism, and collectivism. External—spiritual locus-of-hope was not significantly predicted by the variables. External—family locus-of-hope was significantly predicted by relational self-esteem and collectivism and external—peer locus-of hope was significantly predicted by relational self-esteem, collectivism, and avoidant attachment style. No significant gender differences in locus-of-hope were found. Conclusions: The results provide further understanding about the construct of locus-of-hope and provide a foundation for future research to continue exploring the role of locus-of-hope in the development and expression of self-esteem and attachment profiles. Currently, within psychology, a widely accepted definition of hope comes from Snyder et al.’s Hope Theory , in whicMore recently, Snyder et al.’s Hope Theory  was exteSnyder  describeThe trait Locus-of-Hope Scale  was deveIn the extension of hope theory, Bernardo  reasonedSubsequent studies have further validated associations between locus-of-hope and individualist and collectivist relational tendencies through correlations with independent and interdependent self-construals (how the self is perceived in relation to others), respectively . ImportaIn addition to re-examining the importance of individualist and collectivist relational tendencies to the locus-of-hope construct, there is also a need to discern how other individual difference variables relate to the construct of locus-of-hope. For instance, the relevance of trait hope is greatly attributed to its associations with measures of subjective well-being and life satisfaction ,9,18. HoIn a subsequent study, focusing on life satisfaction along with personal and relational self-esteem, internal locus-of-hope, external—family, and external—peer locus-of-hope scales demonstrated positive correlations with scale scores on life satisfaction and relational self-esteem scales . The extThe current study also sought to broaden knowledge on locus-of-hope by examining associations with adult attachment. According to Ainsworth and Bowlby’s attachment framework , three pThe relevance of hope to attachment relationships was introduced in Snyder’s earlier work  suggestiGender differences in Snyder’s internal trait hope  have beeBased on the above review, it is clear that there exists a comparatively small amount of research on, and therefore understanding of, locus-of-hope and its relation to individual difference variables. In light of this, the present study was designed to provide additional insights into the construct to aid in the understanding of cognitive hope, its use, and its significance across individuals. To achieve this, the present study had three aims. First, to assess whether the four locus-of-hope dimensions demonstrate expected correlations with individual-level individualism and collectivism within a sample with diverse cultural backgrounds. In line with Bernardo’s predictions , individParticipants consisted of 549 university students  enrolled in an undergraduate management and organizational studies class. Participants were compensated with a research credit to fulfill a component of their course. The study was completed individually and online. A total of 120 different cultures or combinations of cultures were reported see . The datThe 40-item Locus-of-Hope Scale  is a selThe short version of the State Locus-of-Hope Scale ,33 contaThe 10-item Rosenberg Self-Esteem Scale  was usedThe Auckland Individualism-Collectivism Scale  was usedThe Experiences in Close Relationship Scale—Short Form  was inclThe Relational Self-Esteem Scale  assessedIn addition to the above instruments, participants responded to demographic questions including fill-in-the-blank questions on gender and general cultural identity.Participants completed the online surveys using Qualtrics. Informed consent was obtained. The study received institutional ethics approval.p < 0.01. Missing data were treated using pairwise deletion. Subsequently, four direct entry regression analyses were computed with the study variables predicting internal locus-of-hope, external—spiritual locus-of-hope, external—family locus-of-hope, and external—peer locus-of-hope, respectively. Regression analyses were completed using R version 4.0.2.Descriptive statistics were calculated, followed by the inter-scale correlations (including gender) using SPSS version 24 . All probabilities were two-tailed, with the level of significance set at Correlations and descriptive statistics are presented in In line with the first hypothesis, results indicate that scores on the internal trait locus-of-hope subscale were significantly correlated with those of internal state locus-of-hope. Similar results were found for external—peer, external—family, and external—spiritual locus-of-hope, indicating that participants’ levels of state and trait hope were highly inter-correlated.Individual-level individualism and collectivism, as measured by scores on the Auckland Individualism-Collectivism Scale , were boInternal locus-of-hope scores were significantly correlated with both personal and relational self-esteem. External—peer and external—family locus-of-hope scores were also significantly correlated with both personal and relational self-esteem. In contrast, scores between external—spiritual locus-of-hope and self-esteem did not reach significance.Scores on the attachment avoidance subscale demonstrated significant negative correlations with both internal and external—family locus-of-hope scores. Correlations between attachment avoidance and external—peer and external—spiritual locus-of-hope were nonsignificant. In contrast, scores on the attachment anxiety subscale were not significantly correlated with internal locus-of-hope. In terms of the external locus-of-hope subscales, attachment anxiety scores showed significant positive correlations with only external—peer locus-of-hope.Point-biserial correlations between gender and internal locus-of-hope were nonsignificant. Similarly, correlations between gender and external—peer, external—family, and external—spiritual locus-of-hope were also nonsignificant. Therefore, contrary to the hypotheses, the results demonstrate no significant gender differences in the use of internal and external trait locus-of-hope.F = 59.08, p < 0.001), accounting for 47% of the variance. Internal locus-of-hope was significantly predicted by self-esteem, relational self-esteem, individualism, and collectivism.F = 2.87, p = 0.006), this model only accounted for 4% of the variance and none of the study variables uniquely and significantly predicted external—spiritual locus-of-hope.F = 35.24, p < 0.001). Specifically, external—family locus-of-hope was significantly predicted by relational self-esteem and collectivism.F = 19.69, p < 0.001). For individual variables, external—peer locus-of-hope was significantly predicted by relational self-esteem, collectivism, and avoidant attachment style.Overall, external—spiritual locus-of-hope was not well predicted by the analyzed variables, in contrast to internal, external—family, and external—peer, which all had above 23% of the variance predicted by the study variables. Among these three locus-of-hope constructs, relational self-esteem was an important predictor for all of them, when examining the 95% confidence intervals. Personal self-esteem was significant only for internal locus-of-hope. Consistent with study expectations, individualism was predictive of internal locus-of-hope, and collectivism predictive of external—family and external—peer. Somewhat surprising is that collectivism also significantly predicted internal locus-of-hope.The purpose of the current study was to explore locus-of-hope in relation to individual-level individualism and collectivism, self-esteem, insecure attachment, and gender within a sample with diverse cultural backgrounds. In particular, this study examines the relatively new construct of sources of external locus-of-hope in addition to the traditional internal locus-of-hope dimension.In line with the prediction that state hope fluctuates within the bounds of trait or dispositional hope , it was The first two hypotheses were confirmed, as positive correlations between individualism and internal locus-of-hope as well as collectivism and the three dimensions of external locus-of-hope were found to be statistically significant. Individualist relational tendencies demonstrated greater magnitude correlations with internal rather than external locus-of-hope, while collectivist relational tendencies showed greater magnitude correlations with the external rather than internal locus-of-hope dimensions . In addition, the regression models demonstrated that internal locus-of-hope was significantly predicted by both individualism and collectivism, with a stronger beta-weight for individualism. External—family locus-of-hope and external—peer locus-of-hope were both significantly predicted by collectivism and not for individualism. For the external—spiritual locus-of-hope scale, collectivism had a positive beta-weight, but the value did not reach significance. These findings provide some support to the theory behind Bernardo’s additional external locus-of-hope dimensions , in whicIn the present study, self-esteem was assessed by examining both personal self-esteem, assessing self-worth, and relational self-esteem, assessing pride with friends and family associations. The hypothesized positive correlations between internal locus-of-hope and the two measures of self-esteem were supported as the correlations were statistically significant and corroborate the general conclusion that internal locus-of-hope relates to measures of well-being. In particular, when predicting the variance in internal locus-of-hope, both personal and relational self-esteem scales predicted significant independent components of variance. The associations between self-esteem and internal locus-of-hope are well-documented and are likely due to the increases in self-efficacy and optimism that ensue from the adoption of internal agency and pathway thinking .The correlation, and regression weights, between the external—spiritual locus-of-hope and self-esteem did not reach significance for both of the self-esteem scales. These results are in partial agreement with past studies ,17. In iDue to conflicting reports in the previous literature, no specific predictions were made for the external—peer and external—family locus-of-hope dimensions in relation to self-esteem. That said, the results of the regression analyses in the current study indicate that both external—peer and external—family locus-of-hope were associated with higher relational self-esteem, similar to the findings of Du and King , but theIn contrast to the internal locus-of-hope, little is understood about how external locus-of-hope is related to self-esteem. While external locus-of-hope dimensions likely involve the positive efficacy evaluations that follow from advancement towards a goal state, as well as perceptions of close others as available and willing to offer support for the advancement of personal goals, understanding the specifics of such mechanisms will be up to future investigations. Overall, internal trait hope has long been recognized as a protective factor of individual quality of life and general well-being within both clinical and non-clinical populations ,42,43,44In partial agreement with the hypotheses, attachment avoidance was significantly and negatively associated with both internal and external—family locus-of-hope. The former result is consistent with Snyder’s theory of hope and attachment  and has Correlations, and regression weights, between attachment anxiety and internal locus-of-hope did not reach significance. This was somewhat surprising considering the amount of past research supporting negative associations between both insecure attachment styles and levels of hope . AttachmThe hypotheses that males would report higher internal locus-of-hope, and women would report higher external locus-of-hope, were not statistically supported. The only significant result found for gender was a small negative correlation with internal state locus-of-hope, indicating that males in the sample had slightly higher internal hope scores, but it should be noted that the gender beta-weight in the direct entry regression model predicting internal locus-of-hope was not significant. The absence of significant results is consistent with studies reporting no significant gender differences on other variables that are conceptually similar to hope as well as the agency and pathway thinking constructs, such as achievement goals, self-efficacy, or motivation ,50,51. TThe present study also included a number of limitations. For example, although participants in the sample identified with a wide variety of cultures that vary in their estimated country-wide rankings of individualism and collectivism, the distribution of the sample was somewhat unbalanced. China (a strongly collectivist culture) accounted for the largest portion of responses (19.4%; see In addition, the cross-sectional and correlational nature of the data prohibits any inference of causality or directionality between the variables. Future research involving longitudinal or experimental design is required to properly understand whether high self-esteem is a trait that fosters locus-of-hope, or vice versa. Similar investigations would benefit the study of locus-of-hope and attachment, as such an understanding might prove important not only theoretically, but also practically, in the application of hope intervention programs ,56. In aIn conclusion, the study showed that the ways in which individuals achieve a sense of hope go beyond the original conceptualization in which agency and pathway thinking are required to come from the individual to whom the goals belong. Rather, the current study validates findings that hope can also be achieved externally, through the motivation and abilities of close others, and that this means of achieving hope is more common among individuals exhibiting collectivist or interdependent relational tendencies. Therefore, this four-dimensional conceptualization of hope represents a more culturally diverse approach to the measurement of cognitive hope across populations. In addition, the results of this study highlight the potential of locus-of-hope in contributing to positive outcomes, such as personal and relational self-esteem, and provides a basis for future investigations on the role of locus-of-hope in the formation of secure and insecure attachment. There remains a long way to go in understanding how individual differences impact the experience and expression of hope as well as the outcomes, both positive and negative, that hope might provide. Fortunately, the adoption and validation of such an inclusive measure represent a strong step in that direction and provide a foundation on which future research may begin properly addressing such questions.That said, the impact of cognitive hope goes far beyond subjective measures of self-esteem and, until recently, its array of positive and protective outcomes was understood as being the result of only the individual’s motivations and abilities. The recent addition of the external dimensions raises questions about the extent to and mechanisms by which external—peer, external—family, and external—spiritual hope similarly contribute to positive personal and relational outcomes. These questions provide opportunities to the field of positive psychology to further explore the role of the additional dimensions in the development of life satisfaction and well-being, beyond what can be explained by the internal locus.


Pectinophora gossypiella (Lepidoptera: Gelechiidae), is a major pest of cotton. In this study, we analyzed the mRNA from pheromone glands of two populations in Israel. We found several virus sequences that were the same in these populations. We identified these viruses based on high-throughput sequencing data and analysis of the assembled transcripts. Through analysis of the sequences, we identified several unique viral sequences representing possible novel viral species. Two of the viral sequences were found in relatively high abundance in pheromone glands. One of the virus sequences was also found through analysis of previous transcriptome sequencing data from the midgut of pink bollworm larvae. This is the first report of these unique viral sequences found in the pink bollworm, and these viruses could be developed to help control this pest around the world, but more research is needed to determine their utility as biological control agents.The pink bollworm, Pectinophora gossypiella to identify viral sequences. The lab population and the field samples carried the same viral sequences. We discovered four novel viruses: two positive-sense single-stranded RNA viruses, Pectinophora gossypiella virus 1  and Pectinophora gossypiella virus 4 , and two negative-sense single-stranded RNA viruses, Pectinophora gossypiella virus 2  and Pectinophora gossypiella virus 3 . In addition, sequences derived from two negative-sense single-stranded RNA viruses that belong to Mononegavirales were found in the data. Analysis of previous transcriptome sequencing data derived from the midgut of pink bollworm larvae of a USA population only identified PecgV1, but no other viruses. High viral sequence coverages of PecgV1 and PecgV4 were observed in both field and lab populations. This is the first report of viral sequences discovered from the pink bollworm. Results from this investigation suggest that the pink bollworm harbors multiple viruses. Further investigation of the viral pathogens may help to develop novel pest management strategies for control of the pink bollworm.In this study, we analyzed the transcriptome obtained from the pheromone gland isolated from two Israeli populations of the pink bollworm  Pectinophora gossypiella (Lepidoptera: Gelechiidae), is a worldwide pest that causes significant yield losses in cotton fields. The larvae of the pink bollworm feed inside flower buds and bolls, where they are well protected from contact to insecticides; hence, application of traditional insecticides is not efficient in controlling the pest. Current control measures for PBW largely depend on the use of transgenic cotton producing the Bacillus thuringiensis (Bt) toxin, which effectively controls this pest [Autographa californicanuclear phlyhedrosis virus (AcNPV) was tested in bait formulation against PBW larvae, which resulted in significantly decreased numbers of larvae and thus boll damage [The pink bollworm (PBW), his pest . The usehis pest . Howeverhis pest . In addihis pest . Recentlhis pest . The usel damage ,6.Viral pathogens of PBW were previously recorded. The infectivity, symptomatology, histopathology and transmission of AcNPV in pink bollworm larvae were investigated . In addiAssembly of high-throughput sequencing data provides a powerful methodology for discovery of viral sequences from insects . AnalysiTwo different populations of pink bollworm were collected in Israel. One was from a laboratory colony (Lab) maintained at the Volcani Institute, Bet-Dagan, Israel, and the other one was collected from a cotton field (Field) near Ein Shemer, Israel, where mating disruption failed . The lab8 and 3.35 × 108 in lab and field populations, while the stranded total RNA-Seq libraries were 8.14 × 107, 5.55 × 107 and 4.88 × 107 in the lab population and 9.91 × 107, 6.38 × 107 and 4.86 × 107 in the field population.Methods for RNA isolation, sequencing library preparation and Illumina sequencing were described previously . Brieflyhttps://www.ncbi.nlm.nih.gov/labs/virus/vssi/#/virus? (1 July 2015)). Contigs that hit viral sequences were selected and further annotated by using the BLASTx program against the NCBI non-redundant (nr) protein databases. Details of the viral sequence search and determination were previously described [The quality of all raw reads was checked using FastQC . The de novo assembly was carried out with the short reads assembling program Trinity . To searescribed . Viral sescribed .https://www.ncbi.nlm.nih.gov/Structure/cdd/wrpsb.cgi (accessed on 14 June 2021) and InterProtScan (https://www.ebi.ac.uk/interpro/search/sequence-search (accessed on 14 June 2021). The RNA-dependent RNA polymerase domain of picorna-like viruses was determined by the online NCBI conserved domain search engine (https://www.ncbi.nlm.nih.gov/Structure/cdd/wrpsb.cgi? (accessed on 14 June 2021) with an E-value of <0.001. The identified RdRP sequences were extracted and used for phylogenetic analysis. Multiple sequence alignments of the core motifs were conducted using CLC genomics Workbench 9.5. For the phylogenetic analysis, the sequences were aligned using the ClustalW method. MEGA 7.0 [The conserved and functional domains of the predicted viral proteins were identified by the Conserved Domain Database (CDD) in NCBI  to viruses in the field population . Out of Amino acid alignment of the six ssRNA viruses between the lab and field populations showed 99% to 100% sequence identity . To asseIn the NCBI/SRA database, we found transcriptomic sequencing data from larval PBW isolated from a USA population (SRA: SRP062867) . We asseIflaviridae. Although protein annotation of PecgV4 showed a close relationship to iflaviruses, its genome orientation is different from that of an iflavirus. For example, the structural and non-structural proteins are arranged in the opposite position in PecgV4 , a single ORF polyprotein of 2948 aa with a predicted molecular weight of 337.77 kDa and a 429-nt 3′ UTR followed by a poly A tail (The PecgV1 polyprotein suggested that PecgV1 is highly homologous to an iflavirus (Helicoverpa armigera iflavirus) isolated from Helicoverpa armigera with 78% identity , which ry A tail A. PecgV4y A tail C. The stDespite the differences in polyprotein structures of PecgV1 and PecgV4, the conserved protein domains identified from PecgV1 and PecgV4 were similar A, includH. armigera and B. mori. The three iflaviruses together with three lepitopteran iflaviruses form a subclade . The L segment encodes RdRP, and M and S encode glycoproteins and nucleocapsid proteins, respectively [−7. BLAST analysis of the RdRP protein of PecgV2 showed a high amino acid identity (62%) to that of Seattle prectang virus (SPV), which is a member of the family Phasmaviridae and was isolated from the green pug (Pasiphila retangulata), a lepidopteran. The M segment of PecgV2 was 2446 nt in length. The top BLASTp hit was 42.47% identity to the glycoprotein of Seattle prectang virus. The conserved domain prediction showed that there is a phlebovirus glycoprotein G2 domain in the middle region . The S segment of PecgV3 was 1701 nt, encoding a potential nucleoprotein with 40.46 kDa. The BLASTp result showed 56.74% identity to the nucleocapsid of Seattle prectang virus; however, CDD analysis did not find any conserved domains.The initial annotation of PecgV2 and PecgV3 suggested that these two viruses were (-ss)RNA viruses belonging to ectively . For PecBunyavirale by the BLASTp search. The L segment was 7827 nt in length and encoded a putative RdRp of 2503 aa with a predicted molecular weight of 287.09 kDa (−74). The alignment of the RdRp from PecgV2-L and PecgV3-L and other (−ss)RNA viruses indicates that the amino acid sequences of their RdRps consist of the pre-motif A and motifs A through E, which are highly conserved in negative-sense RNA viral polymerases and common to all other Bunyavirales characterized to date [−15). The online programs TMHMM and TMPred showed there are two transmembrane domains in the middle region and one transmembrane domain in the C-terminus. This result is expected as multiple internal transmembrane domains are conserved in Phenuiviridae. The S segment of PecgV3 is 2362 nt in length and encoded for a unique protein of 276 aa with a predicted mass of 31.08 kDa. Protein annotation showed that it was closely associated with the N protein of members of the genus Phasivirus. CDD analysis showed there is a Tenuivirus/Phlebovirus nucleocapsid protein domain .The genome of PecgV3, with its three segments, was recovered from the sequencing reads. The three encoded viral proteins hit Hubei lepidoptera virus 1 (HLV1) of 7.09 kDa A. The L  to date   or Formica exsecta virus 1 (FeV1), members of Monoegavirales. A full-length RdRP of FeV4 or FeV1 is 1877aa; hence, the two CDS of the contigs are actually truncated sequences. In addition, no sequences of other viral genes related to the RdRPs were assembled from the reads, and these results suggest that the RdRP hit contigs were putatively derived from the EVE of the host.In mammals, retroviral envelope genes play an important role in cell–cell fusion during placentation, and they might have anatomic and immunological functions . The twoNew viruses are difficult to discover with the traditional viral detection methods because they require isolation of viruses followed by whole genome sequencing. However, high-throughput next-generation sequencing technologies and bioinformatics have been applied to virus discovery in various organisms, including humans ,24, arthThe pink bollworm, as a pest species, quickly spread around the world as it was first reported on infested cotton in Egypt in 1913  and in 1Iflaviridae and Dicistroviridae could cause serious disease symptoms to the host insect. For instance, Aphid lethal paralysis virus (ALPV), a dicistrovirus, could significantly reduce aphid populations [To date, four genomic types of picornaviruses isolated from insects have been identified. These viruses share similar conserved domains: the RdRp (cd0169) and Rh-V domains and other motifs. Members of ulations ,38. Diciulations . The NSPPhasmaviridae. Viruses of this family are known to be isolated from insect hosts, while PecgV3 relates to viruses in the family Phenuiviridae, which infect both vertebrates and invertebrates. Hence, the pink bollworm is likely the host of PecgV2 and PecgV3. It has been proposed that plant negative RNA viruses evolved via horizontal virus transfer from vertebrates and mediated by arthropod vectors. Therefore, it is reasonable that members of Bunyavirales, mostly detected in plants and vertebrates, can be found in invertebrates, such as the pink bollworm in this study and other insects. The ancestors of plant and vertebrate negative RNA viruses are thought to have evolved from a natural reservoir which is represented by invertebrates via horizontal virus transfer, indicating that diverse invertebrates show similar viruses in the same ecological niche [PecgV2 and PecgV3 were defined as (-ss)RNA viruses. Based on the amino acid alignment and phylogenetic analysis, it is clear that the sequences of PecgV2 and PecgV3 were derived from different viruses. PecgV2 is a virus in the family al niche . InvestiS. frugiperda cells [S. frugiperda larvae . We identified two transcripts likely derived from EVEs of unknown rhabdoviruses. The transcript encoding the N gene also hit other uncharacterized genes of several lepidopterans (data not shown), suggesting that the EVEs of mononegaviruses are common in these insects. Recovery of transcripts of the EVEs suggested that the EVEs were active. However, the coding regions of the contigs encoded two truncated RdRp sequences, indicating that the partial RdRp might not have biological functions. Some evidence has pointed to RNA-level functions for insect nonretrovial EVEs [EVE sequences were commonly observed in insect genomes . In addida cells . Rhabdorial EVEs ,44, but Rhopasiphum padi) [Acyrthosiphon pisum) and R. padi [In this study, we found the PBWs were infected by multiple RNA viruses. Picorna-like virus isolated from the pink bollworm population of Egypt was previously reported . An Egypum padi) ,38. Howe R. padi . Hence,


This paper proposes a first monetary measure of the private costs of celiac disease, including intangible costs  in Switzerland. This auto-immune disease damages the intestine when patients ingest gluten. The only treatment currently available is a gluten-free diet, which implies great nutritional constraints. To get a monetary equivalent of the costs borne by celiac patients, we used a contingent valuation. The scenario suggested to celiac patients a treatment in form of a daily pill, which would allow them to eat normally and avoid any physical pain from celiac disease. Mean Willingness To Pay (WTP) for the treatment is found to be around CHF 87 (approx. USD 87) per month. WTP is positively influenced by direct and indirect costs of the disease. Oppositely, individuals, who find the gluten-free diet healthier are willing to pay less. Finally, unlike symptoms before diagnostic, the current presence or intensity of physical symptoms are found to be insignificant. The latter result can be explained by the fact that, individuals facing stronger symptoms are more likely to adhere strictly to the GFD and hence to reduce their frequency. Celiac disease is a chronic auto-immune disease that appears in genetically predisposed individuals. It causes an atrophy of the intestinal villi in reaction to the ingestion of gluten, contained in wheat, barley, rye, and their derivatives . Celiac The only treatment is a strict gluten-free diet (GFD). In general, food with less than 20 particles per million (ppm) is considered harmless for celiac patients , which iLiving with celiac disease can be difficult as it might cause unpleasant symptoms and concerns. Celiac patients show a higher risk for certain infections such as tuberculosis, influenza or clostridium difficile (see ). In addThe OECD  accountsSome direct costs, such as the premium paid for gluten-free food, and indirect costs such as the extra time spent cooking and organizing and the loss of productivity have been specifically assessed for the case of Switzerland in Soler . Some otThe present study estimates the total private costs related to celiac disease in Switzerland, thanks to a contingent valuation (CV). The CV method is a stated preferences method, which is widely used in environmental economics . It alloAssessing the costs of a disease is crucial in a cost–benefit framework. First, a measure of costs can provide policy-makers with arguments to encourage a better labeling of food products and foster the provision of gluten-free food. The food industry could also consider these results to shape its gluten-free food pricing or extend its gluten-free products choice. Finally, a measure of WTP is an interesting tool for the pharmaceutical industry, which could decide to invest in research and development if WTP covers the costs. This measure could also help assessing the evolution of CD’s burden over time and evaluate whether given policy measures have an impact on patients’ well-being.The remainder of the paper is structured as follows: Sect. Other studies have used CV to estimate the burden of a disease or its treatment. For example, Lin et al.  assess tLi et al.  asked paBeikert et al.  assessedStudies suggest that different factors might be affecting the well-being of celiac patients and thus their WTP, namely adherence to the diet , 51, preIn several studies, however, celiac patients did not seem to have a lower health-related quality of life compared to the general population  [Canada]WTP could also be positively affected by the magnitude of direct and indirect costs foregone by patients and their income. For example, a person spending a high amount on gluten-free food might be more willing to pay for an alternative treatment. The same applies to someone who considers they would have better job opportunities without living with negative consequences of the disease.Based on the literature, which measures quality of life for celiac patients mentioned above, we expect patients experiencing strong symptoms to be willing to pay more and those with supportive friends and relatives to be willing to pay less. The effect on WTP of the extent to which patients adhere to the diet is ambiguous. Patients could be adhesive because they appreciate the GFD—in which case this should decrease WTP—or because they are subject to strong symptoms following the absorption of gluten—in which case this should increase WTP.To our knowledge, only Norström et al.  have useOther methodologies can be used to assess the burden and the costs of celiac disease. For example, Hershcovici et al.  measure An online survey“Imagine now that a pharmaceutic lab proposes a new treatment for celiac disease in the form of a daily pill. This pill would prevent the body’s auto-immune reaction following the ingestion of gluten and would thus allow you to eat normally, without danger nor physical issues. The pill would have no side effects. Before answering, think about the advantages and disadvantages of celiac disease and its current treatment, the gluten-free diet. Would you be willing to buy this treatment?”.The contingent question is framed in three steps. The first step is conceived to identify people who would not buy the treatment. It is worded as follows: If the answer is “No”, then the respondent is guided to a follow-up question aiming at distinguishing protest bidders from zero bidders. The literature indeed points out the need to treat protest bidders differently from zero bidders . Since tThe second step of the contingent question aims at eliciting WTP. There are several ways to proceed in the literature, which all have advantages and disadvantages. The chosen elicitation method is a payment card system. Although this method suffers from the anchoring problem, the lower cognitive burden and the statistical efficiency compared to the open-ended and dichotomous-choice format, respectively , 2, led We paid particular attention to reducing well-known biases inherent in CV. First, the hypothetical bias may lead to an overstatement of WTP Loomis . ParticiA concern about strategic behavior and incentives has been discussed in the literature . 87% of the answers are from members of the celiac disease association.The representativity of the sample is difficult to assess since characteristics of people suffering from celiac disease in the whole population are not available. In our sample, 75% of the respondents are women and 25% are men, which seems to confirm that the disease is more prevalent among the female population . The aveRespondents are more educated than the Swiss average with 37% of respondents having completed higher education compared to 29% in the population. The professional secondary training (apprenticeship) is underrepresented with only 25% of respondents having completed it, compared to 36.4% of the population OFS . This isThe median gross household income in the sample is CHF 9000. The distribution seems similar to the Swiss resident population OFS . The aveTheir general health state was judged good or very good by 90% of the respondents. Those who have either other diseases or allergies/intolerances have a lower health on average. 15% of the respondents report none or very mild symptoms before diagnosis. The symptoms range is quite large confirming the observed variety of symptoms in the previous literature. Bowel movement problems and stomachache seem to be the most common as shown in Fig. The variables used in the empirical analysis are presented in Table Income corresponds to the monthly gross personal income. We decided to include the personal rather than household income in the empirical analysis but results are qualitatively similar when using the household income but less significant. Extracost is the amount that respondents pay extra for gluten-free food, per month and per person. These extra costs are considerable compared to the personal income, since 2%, on average, are spent specifically for the purchase of gluten-free food. This amounts to 102 CHF on average, 450 being the maximum in our sample.Labor market indirect costs is a dummy variable indicating whether the respondent faces professional difficulties linked with celiac disease. It takes the value of 1 if the respondent has missed workdays over the last three months due to celiac disease, if the respondent would increase her worktime if she did not suffer from celiac disease, if the diet is a criterion to accept a new job opportunity, or if a treatment would offer more job opportunities. 17% of our sample faces labor market indirect costs.GFDhealthy is a dummy variable, which indicates whether respondents find GFD healthier than regular diet. It is based on a Likert scale, and if the statement “The gluten-free diet makes you eat more healthily.” Is answered by either “somewhat agree” or “strongly agree”, it is coded as 1. Overall, 55% of respondents find GFD healthier.Logistics is a categorical variable, based on the same scale as the previously described GFDhealthy with the statement “You regularly face logistic difficulties caused by your particular diet.” Logistic difficulties seem to be an issue that a majority of our sample faces. 69% strongly or somewhat agree with the statement.Membership is a dummy indicating whether the respondent is a member of the celiac disease association. 88% of the final sample are members.CDAT) measures the adherence to the diet and was computed with the indicator by Leffler et al. [The celiac Dietary Adherence Test  agree with the statement that their close friends or family are understanding of their special needs required by the diet.A third of the respondents had involuntarily eaten gluten at least once during the past four weeks, suggesting that the GFD is still a daily challenge and that the awareness of restaurant staffs or cross-contamination issues could probably be improved. On the other hand, 20% of respondents had eaten gluten voluntarily during the same time span. Unsurprisingly, a negative correlation is observed between the number of accidental/voluntary gluten absorptions and their adverse impact on respondent’s health.11 protest bidders were identified in our sample, which corresponds to a proportion of 7%. This low proportion is probably due to respondents’ interest in the survey. Since respondents self-select, it is indeed likely that only interested people took the survey. To avoid an extra selection bias potentially arising when dropping protest, we compare protest characteristics with non-protests. Protests are no different on the basis of socio-economic variables. Furthermore, a probit regression revealed no impact of variables related to respondent’s disease on the probability to protest. This check allow us excluding selection bias in this case and safely dropping protest answers from the sample .Regarding the hypothetical bias, there is no consensus on how to deal with uncertainty . To stayIn addition to the mean WTP resulting directly from the answers, we perform multinomial regressions, to identify potential determinants of WTP. Theoretically, as explained in the literature review section, WTP reveals celiac disease patients’ preferences and income. It is also influenced by the physical, social and monetary inconveniences linked with celiac disease as well as by potential ancillary benefits from the GFD. We choose the specifications accordingly and propose different models. We base our favorite model on overall and variable specific significance levels, as well as on the Bayes Information Criteria (BIC), to foster parsimony.WTP is the willingness to pay for the celiac disease treatment, Income is the respondent’s gross personal income, Extracost is the extra cost stated by the respondent for the GFD, Labourcosts is a dummy variable indicating whether the respondent faces indirect costs in her professional activity, GFDhealthy indicates whether respondent think the GFD allows her to eat more healthy and Logistics indicates whether the respondent faces regular logistical difficulties linked with her diet.The most parsimonious parametric model, recommended by the BIC is the following:The fact that linear models like Ordinary Least Squares (OLS) predict a dependent variable on both negative and positive values is an important drawback in our case. Indeed, since our valuated good is private, respondents have the choice to purchase it or not and would not need to be compensated. There is, therefore, no reason to state negative WTP. Hence prediction of negative WTP should be ruled out. The importance of the WTP statistical distribution has been highlighted in . A GenerAmong respondents, excluding protest bidders, 83% were willing to pay a positive amount for the treatment and 17% were considered real zeros. The positive bidders were willing to pay CHF 10 up to CHF 1000 per month. As presented in Table n = 14) in the comments: having an easier social life.The main advantage of this hypothetical treatment, for more than 80% of the respondents, was “easier organization”, followed by “less frustration” and “be able to eat more palatable food”. An answer that was not suggested came up several times . This is quite surprising as health is generally a shared “cost” among families or households: it was, therefore, expected to be better linked. This is perhaps due to the format of the question. It was asked personally to the respondent, who is not in a position to discuss it with other members of the household whether they would agree to pay for this hypothetical medicine.Unsurprisingly, the extra costs of the GFD borne by celiac respondents also influence WTP positively. One CHF extra costs would lead to a 0.4–0.5 CHF increase in WTP. The magnitude of this coefficient may seem surprising, since, if respondents integrated all costs in their WTP, all increases in costs should be reflected 1 to 1 in WTP. However, the smaller than 1 coefficient may be explained by unobserved positive effects of the GFD . For example, it could be explained by the fact that respondents might be reluctant to trade gluten-free food for swallowing a pill every day. The medicine would, therefore, only be a weak substitute to gluten-free food.Indirect costs borne by respondents on the labor market also have an important impact on WTP. Respondents who answered that they would have better work conditions without celiac disease have a higher WTP ceteris paribus. In comparison with the mean WTP, the difference is considerable being between 37 and 51 CHF per month.An interesting finding is that those who agree with the statement that GFD is healthier are willing to pay significantly less than the others. Respondents who think that the GFD is healthy are willing to pay 42–59 CHF less per month.Agreeing with “experiencing regular logistical/organizational difficulties” or “choosing holiday destinations according to the availability of gluten-free food” is significant in some specifications. People agreeing with either statement would be willing to pay around CHF 18 more. Furthermore, the biggest advantage of the medicine is “easier organization”, which confirms the importance of logistical costs in celiac patients’ life.Table As expected, willingness to pay is positively correlated to personal income: a 1000 CHF increase in annual income would lead to a 7–8 CHF increase in WTP. However, household income and equivalent household income are less significant (results not shown). This is quite surprising as health is generally a shared “cost” among families or households: it was, therefore, expected to be better linked. This is perhaps due to the format of the question. It was asked personally to the respondent, who is not in a position to discuss it with other members of the household whether they would agree to pay for this hypothetical medicine.Unsurprisingly, the extra costs of the GFD borne by celiac respondents also influence WTP positively. One CHF extra costs would lead to a 0.4–0.5 CHF increase in WTP. The magnitude of this coefficient may seem surprising, since, if respondents integrated all costs in their WTP, all increases in costs should be reflected 1 to 1 in WTP. However, the smaller than 1 coefficient may be explained by unobserved positive effects of the GFD . For example, it could be explained by the fact that respondents might be reluctant to trade gluten-free food for swallowing a pill every day. The medicine would, therefore, only be a weak substitute to gluten-free food.Indirect costs borne by respondents on the labor market also have an important impact on WTP. Respondents who answered that they would have better work conditions without celiac disease have a higher WTP ceteris paribus. In comparison with the mean WTP, the difference is considerable being between 37 and 51 CHF per month.An interesting finding is that those who agree with the statement that GFD is healthier are willing to pay significantly less than the others. Respondents who think that the GFD is healthy are willing to pay 42–59 CHF less per month.Agreeing with “experiencing regular logistical/organizational difficulties” or “choosing holiday destinations according to the availability of gluten-free food” is significant in some specifications. People agreeing with either statement would be willing to pay around CHF 18 more. Furthermore, the biggest advantage of the medicine is “easier organization”, which confirms the importance of logistical costs in celiac patient’s life.Adherence to the GFD, as measured by the indicator CDAT appears to be a significant determinant of the willingness to pay in only one specification: the less adherent, the more willing to pay. This would imply that people who do not follow too strictly their GFD see it as more of a burden than those who strongly comply.Being a member of the celiac disease association is a significant positive determinant of the willingness to pay. Members are ready to pay, depending on the specification, 57–63 CHF more per month than non-members. Keeping in mind that non-members are underrepresented in the sample, it seems that active involvement with the disease translates into higher motivation to invest in an alternative treatment. The fact that members also pay CHF 65 every year for the membership to the association hints in this direction, although membership also brings other opportunities.Current symptoms seem not to have an impact on willingness to pay contrary to having symptoms before diagnosis, which is highly significant in all specifications and also of a large magnitude (around 16 CHF for each degree of intensity). This probably indicates that people, who suffered from strong physical symptoms follow the GFD more strictly and thus suffer from less symptoms currently.On the one hand, the GFD has ancillary social benefits, such as giving the possibility to make new friends, which significantly decrease WTP from about 62–66 CHF. On the other hand, social costs seem not very important in the determination of WTP, since support from family and friends is not a statistically significant determinant of the willingness to pay. However, this does not necessarily imply that it is not an important factor in the well-being of the patients. Indeed, as there is little variation in this item among respondents it probably does not statistically explain the amount people are willing to pay.Finally, the fact that the GFD improved cooking talent and the time spent cooking are no significant determinants of WTP. This is not surprising, since acquired cooking talent would not diminish after buying the hypothetical treatment, although it might not further improve. In addition, respondents do not report spending more time on cooking than the regular population according to OFS .Coefficients resulting from the GLM estimations of specification (1) are available in Table We provide the results of the Kaplan–Meier estimator, whose survival function is presented in Fig. Without questioning the validity of our results, several limitations have to be acknowledged. Although the general social characteristics are not too different from the general population, we cannot exclude some kind of self-selection bias among respondents since the survey, which hinted at an economic study of the costs of celiac disease and might have attracted less people who do not think it is costly. Some debriefing questions also suggest that respondents did not answer completely rationally or did not fully understand some questions. When they were asked a follow-up question of how much they would pay if the gluten-free diet did not imply an additional cost, the difference between the first and the second answer was not necessarily equal to the amount they had indicated as costs for the diet. Given the complexity of this question, we confidently decided to drop it from the analysis.Assessing the total costs of a disease is crucial in a cost–benefit framework. For celiac disease, in particular, a measure of costs can provide policy-makers with arguments related to food policy. A strict enforcement of the ordinance on foodstuffsThese measures would reduce the frequency of contamination of celiac patients, thereby increasing their adherence and lowering complications. This would also reduce intangible costs, as it would be less stressful to eat outside of home for celiac patients.The food industry could also consider these results to shape its pricing policies or supply a bigger variety of gluten-free products. If respondents are willing to pay for a treatment, it is likely that they are also willing to pay for more palatable and more varied gluten-free food. A better availability of gluten-free food would allow a much easier organization and would probably increase adherence to GFD, which in the end, would reduce intangible costs.The pharmaceutical industry could use this WTP information to decide whether to invest in research and development. Indeed, the most effective way of reducing the costs in the long run would probably be to find a cure to this disease. Therefore, ongoing efforts towards a medication should continue and the funding of the research is necessary.Other contingent valuations on the burden of celiac disease would allow for interesting comparisons over time or across countries. In addition, another contingent valuation could be organized with another elicitation method to have a second estimate of the private costs in Switzerland.This paper proposes a first monetary measure of the private costs, including intangible costs, of celiac disease in Switzerland thanks to a contingent valuation. Respondents were willing to pay CHF 10 up to CHF 1000 per month for the treatment. Mean WTP is found to be CHF 87 (75–150) per month or CHF 1044 per year. This amount compares with costs of other illnesses. Celiac disease patients seem to be willing to pay less than prostate cancer patients in Li et al.  or multiWTP is positively influenced by direct and indirect costs of the disease. In particular, individuals, who spend more on gluten-free food and those facing more constraints on the labor market are willing to pay more than others. The intensity of logistical constraints also affects WTP positively. On the other hand, individuals, who find the GFD healthier are willing to pay less. Finally, unlike symptoms before diagnostic, the current presence or intensity of physical symptoms are found to be insignificant. The latter result can be explained by the fact that, individuals facing stronger symptoms are more likely to adhere strictly to the GFD and, hence, to reduce their frequency.The results confirm that there are substantial intangible costs that seem to be mainly composed of an impaired social life, a more stressful organization and indirect costs on the labor market, whereas current physical symptoms do not influence WTP.