Cost-effectiveness of rabies post-exposure prophylaxis in the context of very low rabies risk: A decision-tree model based on the experience of France |
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| Affiliation: | 1. Université Paris Dauphine, LEDa/LEGOS, F-75016, Paris, France;2. Institut Pasteur, Unité Dynamique des lyssavirus et adaptation à l’hôte, National Reference Center for Rabies, F-75015 Paris, France;3. Institut Pasteur, CAR/CMIP/CINP, F-75015, Paris, France;4. IAME, UMR 1137, INSERM, F-75018 Paris, France;5. UPMC Univ Paris 06, ED393, F-75005, Paris, France;6. Univ Pierre et Marie Curie, Cellule Pasteur UPMC, F-75015, Paris, France;7. Institut Pasteur, Unité d’Epidémiologie des Maladies Emergentes, F-75015, Paris, France;8. Assistance Publique Hôpitaux de Marseille, CHU Nord, Pôle Infectieux, Institut Hospitalo-Universitaire Méditerranée Infection, F-13015 Marseille, France;9. Aix Marseille Université, Unité de Recherche en Maladies Infectieuses et Tropicales Emergentes (URMITE), UM63, CNRS 7278, IRD 198, Inserm 1095, Faculté de Médecine, F-13005 Marseille, France;10. AP-HP, Hôpital Bichat, Service de Maladies Infectieuses, F-75018 Paris, France;11. Univ Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France;1. Department of Vascular Surgery, University Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China;2. Department of Medical Oncology, West China Medical School, Sichuan University, Chengdu, China;3. Department of Oncology, Sichuan Provincial People''s Hospital, Chengdu, China;1. Dartmouth-Hitchcock Medical Center, Section of Allergy and Immunology, Lebanon, New Hampshire;2. Dartmouth Geisel School of Medicine, Hanover, New Hampshire;3. Children''s Hospital Colorado, University of Colorado School of Medicine, Section of Allergy and Immunology, Food Challenge and Research Unit, Aurora, Colorado;1. Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Windmill Road, Oxford, OX3 7LD, United Kingdom;2. NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom;3. School of Medicine and Public Health, University of Newcastle, New South Wales, Australia;1. National Reference Laboratory for Rabies in Animals, Department of Molecular Diagnostics, FMD, Virological, Rickettsial & Exotic Diseases, Athens Veterinary Center, Ministry of Rural Development and Food, Athens, Greece;2. Laboratory of Epidemiology, Biostatistics and Animal Health Economics, School of Veterinary Sciences, Faculty of Health Science, University of Thessaly, Karditsa, Greece;3. Department of Imports, Exports and Intraunion Trade of Live Animals and Products of Animal Origin, Animal Health Directorate, Ministry of Rural Development and Food, Athens, Greece;4. Companion Animal Clinic, School of Veterinary Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece;1. Federal Budget Institute of Science Central Research Institute for Epidemiology, Russian Inspectorate for Protection of Consumer Right and Human Welfare, Moscow, Russia;2. RAS Institute of Occupational Health, Moscow, Russia;3. Chumakov Institute of Poliomyelitis and Viral Encephalitides, Moscow, Russia;4. Martsinovsky Institute of Medical Parasitology and Tropical Medicine, Sechenov First Moscow State Medical University, Moscow, Russia;5. Omsk Research Institute of Natural Foci Infections, Omsk, Russia;6. Institute of Virology, University of Bonn Medical Centre, Bonn, Germany;7. German Centre for Infection Research, partner site Bonn-Cologne, Germany |
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| Abstract: | IntroductionBenefit-risk of different anti-rabies post-exposure prophylaxis (PEP) strategies after scratches or bites from dogs with unknown rabies status is unknown in very low rabies risk settings.Design and settingA cost-effectiveness analysis in metropolitan France using a decision-tree model and input data from 2001 to 2011.PopulationA cohort of 2807 patients, based on the mean annual number of patients exposed to category CII (minor scratches) or CIII (transdermal bite) dog attacks in metropolitan France between 2001 and 2011.InterventionsFive PEP strategies: (A) no PEP for CII and CIII; (B) vaccine only for CIII; (C) vaccine for CII and CIII; (D) vaccine+ rabies immunoglobulin (RIG) only for CIII; and (E) vaccine for CII and vaccine+ RIG for CIII.Main outcomes measuresThe number of deaths related to rabies and to traffic accidents on the way to anti-rabies centers (ARC), effectiveness in terms of years of life gained by reducing rabies cases and avoiding traffic accidents, costs, and incremental cost-effectiveness ratios (ICER) associated with each strategy.ResultsStrategy E led to the fewest rabies cases (3.6 × 10−8) and the highest costs (€1,606,000) but also to 1.7 × 10−3 lethal traffic accidents. Strategy A was associated with the most rabies cases (4.8 × 10−6), but the risk of traffic accidents and costs were null; therefore, strategy A was the most effective and the least costly. The sensitivity analysis showed that, when the probability that a given dog is rabid a given day (PA) was >1.4 × 10−6, strategy D was more effective than strategy A; strategy B became cost-effective (i.e. ICER vs strategy A <3 × French Gross Domestic Product per capita) when PA was > 1.4 × 10−4.ConclusionsIn the metropolitan France's very low rabies prevalence context, PEP with rabies vaccine, administered alone or with RIG, is associated with significant and unnecessary costs and unfavourable benefit-risk ratios regardless to exposure category. |
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| Keywords: | Rabies Post-exposure prophylaxis Cost-effectiveness Road accident Adverse event |
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