Abstract
BackgroundRecent pertussis outbreaks have prompted re-examination of post-exposure prophylaxis (PEP) strategies, when immunization is not immediately protective. Chemoprophylaxis is recommended to household contacts; however there are concerns of clinical failure and significant adverse events, especially with erythromycin among infants who have the highest disease burden. Newer macrolides offer fewer side effects at higher drug costs. We sought to determine the cost-effectiveness of PEP strategies from the health care payer perspective.MethodsA Markov model was constructed to examine 4 mutually exclusive strategies: erythromycin, azithromycin, clarithromycin, or no intervention, stratified by age group of contacts (“infant”, “child”, and “adult”). Transition probabilities, costs and quality-adjusted life years (QALYs) were derived from the literature. Chronic neurologic sequelae were modeled over a lifetime, with costs and QALYs discounted at 5%. Associated health outcomes and costs were compared, and incremental cost-effectiveness ratios (ICER) were calculated in 2012 Canadian dollars. Deterministic and probabilistic sensitivity analyses were performed to evaluate the degree of uncertainty in the results.FindingsAzithromycin offered the highest QALYs in all scenarios. While this was the dominant strategy among infants, it produced an ICER of $16,963 per QALY among children and $2,415 per QALY among adults. Total QALYs with azithromycin were 19.7 for a 5-kg infant, 19.4 for a 10-year-old child, and 18.8 for a 30-year-old adult. The costs of azithromycin PEP among infants, children and adults were $1,976, $132 and $90, respectively. While results were sensitive to changes in PEP effectiveness (11% to 87%), disease transmission (variable among age groups) and hospitalization costs ($379 to $59,644), the choice of strategy remained unchanged.InterpretationPertussis PEP is a cost-effective strategy compared with no intervention and plays an important role in contact management, potentially in outbreak situations. From a healthcare payer perspective, azithromycin is the optimal strategy among all contact groups.
Highlights
In the pre-vaccine era, pertussis was a major childhood illness affecting children primarily under 10 years of age, and a major cause of death among infants under 1 year [1]
Chronic neurologic sequelae were modeled over a lifetime, with costs and quality-adjusted life years (QALYs) discounted at 5%
Caused by Bordetella pertussis, the disease was pandemic throughout the 20th century, with cyclical epidemic peaks every 2 to 5 years [1]
Summary
In the pre-vaccine era, pertussis was a major childhood illness affecting children primarily under 10 years of age, and a major cause of death among infants under 1 year [1]. Caused by Bordetella pertussis, the disease was pandemic throughout the 20th century, with cyclical epidemic peaks every 2 to 5 years [1]. Prolonged pertussis outbreaks have recently been reported across North America [6,7,8,9], prompting re-examination of control and prevention strategies [10]. In 2010, 101 cases of pertussis were reported in Ontario (0.8 cases per 100,000 population) [6]. Following a 2011–2012 outbreak, 792 cases were reported across both years, or 5.9 per 100,000 population. Recent pertussis outbreaks have prompted re-examination of post-exposure prophylaxis (PEP) strategies, when immunization is not immediately protective. We sought to determine the cost-effectiveness of PEP strategies from the health care payer perspective
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