Cost Of Post-exposure Prophylaxis Research Articles

Cost Analysis of Post Exposure Prophylaxis of Rabies in A Tertiary Care Centre- A Cross Sectional Study

India is a rabies endemic country with the highest incidence of rabies cases with approximately 30,000 deaths per year and more than 1,000,000 people undergoing anti rabies vaccination every year. Around 30 to 60% of pre exposure prophylaxis are given to children below the age of 15.The following study was conducted in the district of Thrissur, in the state of Kerala. This study was conducted to analyze the cost of post exposure prophylaxis and to compare assumed cost of pre exposure prophylaxis. Our study included 213 patients attended anti rabies clinic for post exposure prophylaxis. Among the group 63.4% were adults and 36.6% were children. Majority were category III exposure The analysis of the direct cost of post exposure vaccination was done and compared with the cost of pre exposure prophylaxis. The post exposure vaccination included 4 doses of Intra dermal rabies vaccination -two site regime (modified Thai red cross regime) along with rabies immunoglobulin for category 3, added up to $ 4540. This was compared with the cost that would have occurred if these patients had previously received pre exposure prophylaxis which was $890. It was found that Pre exposure prophylaxis came to only to one fifth the cost of post exposure prophylaxis. We infer that Pre exposure prophylaxis is a cost effective strategy which can aid in the control and elimination of rabies in endemic countries. th

Cost-effectiveness of rabies post exposure prophylaxis in Iran.

The rabies is one of the most important officially-known viral zoonotic diseases for its global distribution, outbreak, high human and veterinary costs, and high death rate and causes high economic costs in different countries of the world every year. The rabies is the deadliest disease and if the symptoms break out in a person, one will certainly die. However, the deaths resulting from rabies can be prevented by post-exposure prophylaxis. To do so, in Iran and most of the countries in the world, all the people who are exposed to animal bite receive Post-Exposure Prophylaxis (PEP) treatment. The present survey aimed to investigate the cost-effectiveness of PEP in southern Iran. The present study estimated the PEP costs from the government`s Perspective with step-down method for the people exposed to animal bite, estimated the number of DALYs prevented by PEP in the individuals using decision Tree model, and computed the Incremental cost-effectiveness Ratio. The information collected of all reported animal bite cases (n=7111) in Fars Province, who referred rabies registries in urban and rural health centers to receive active care. Performing the PEP program cost estimated 1,052,756.1 USD for one year and the estimated cost for the treatment of each animal bite case and each prevented death was 148.04 and 5945.42 USD, respectively. Likewise 4,509.82 DALYs were prevented in southern Iran in 2011 by PEP program. The incremental cost-effectiveness ratio for each DALY was estimated to be 233.43 USD. In addition to its full effectiveness in prophylaxis from rabies, PEP program saves the financial resources of the society, as well. This study showed performing PEP to be more cost-effective.

The burden of rabies in Tanzania and its impact on local communities.

BackgroundRabies remains a major public health threat in many parts of the world and is responsible for an estimated 55,000 human deaths annually. The burden of rabies is estimated to be around US$20 million in Africa, with the highest financial expenditure being the cost of post-exposure prophylaxis (PEP). However, these calculations may be substantial underestimates because the costs to households of coping with endemic rabies have not been investigated. We therefore aimed to estimate the household costs, health-seeking behaviour, coping strategies, and outcomes of exposure to rabies in rural and urban communities in Tanzania.Methods and FindingsExtensive investigative interviews were used to estimate the incidence of human deaths and bite exposures. Questionnaires with bite victims and their families were used to investigate health-seeking behaviour and costs (medical and non-medical costs) associated with exposure to rabies. We calculated that an average patient in rural Tanzania, where most people live on less than US$1 per day, would need to spend over US$100 to complete WHO recommended PEP schedules. High costs and frequent shortages of PEP led to poor compliance with PEP regimens, delays in presentation to health facilities, and increased risk of death.ConclusionThe true costs of obtaining PEP were twice as high as those previously reported from Africa and should be considered in re-evaluations of the burden of rabies.

Safety and pharmacokinetics of a human monoclonal antibody to rabies virus: A randomized, dose-escalation phase 1 study in adults

BackgroundRabies is an essentially fatal disease that is preventable with the timely administration of post-exposure prophylaxis (PEP). The high cost of PEP, which includes vaccine and hyperimmune globulin, is an impediment to the goal of preventing rabies in the developing world. Recently a recombinant human IgG1 anti-rabies monoclonal antibody (SII RMab) has been developed in India to replace serum-derived rabies immunoglobulin. The present study was conducted to demonstrate the safety of SII RMab and to determine the dose resulting in neutralizing serum antibody titers comparable to human rabies immunoglobulin (HRIG) when administered in conjunction with rabies vaccine in a simulated PEP regimen. MethodsThis randomized, open label, dose-escalation phase 1 study was conducted in healthy adults at a large tertiary care, referral, public hospital in India. Safety was assessed by active surveillance for adverse events along with standard laboratory evaluations and measurement of anti-drug antibodies (ADA). Anti-rabies antibody levels were measured by rapid fluorescent focus inhibition test (RFFIT) and ELISA. The study duration was 365 days. FindingsSII RMab was well tolerated with similar frequency of local injection site reactions to HRIG. The geometric mean concentrations of rabies neutralizing antibody in the vaccine plus SII RMab 10IU/kg cohort were comparable to the vaccine plus HRIG 20IU/kg cohort throughout the 365-day study period; day 14 geometric mean concentrations 23.4IU/ml (95% CI 14.3, 38.2) vs. 15.3IU/ml (95% CI 7.72, 30.3; p=NS), respectively. Future post-exposure prophylaxis studies of SII RMab at a dose of 10IU/kg in conjunction with vaccine are planned.

Economic Evaluation of Vampire Bat (Desmodus rotundus)Rabies Prevention in Mexico

Vampire bat rabies causes significant impacts within its endemic range in Mexico. These impacts include livestock mortality, animal testing costs, post-exposure prophylaxis costs, and human mortality risk. Mitigation of the impacts can be achieved by vaccinating livestock and controlling vampire bat populations. A benefit-cost analysis was performed to examine the economic efficiency of these methods of mitigation, and Monte Carlo simulations were used to examine the impact that uncertainty has on the analysis. We found that livestock vaccination is efficient, with benefits being over six times higher than costs. However, bat control is inefficient because benefits are very unlikely to exceed costs. It is concluded that when these mitigation methods are judged by the metric of economic efficiency, livestock vaccination is desirable but bat control is not.

Epidemiological investigations of human rabies in China.

BackgroundThe epidemic of rabies showed a rising trend in China in recent years. To identify the potential factors involved in the emergence, we investigated and analyzed the status and characteristics of human rabies between 1996 and 2008. Moreover, the status of rabies infection and vaccination in dogs, and prophylaxis of humans after rabies exposure were analyzed.MethodsHuman rabies data in China between 1996 and 2008 collected from the annual reports of Chinese Center for Disease Control and Prevention (China CDC) were analyzed. To investigate the status of dogs and postexposure prophylaxis (PEP) of humans, brain specimens of domestic dogs were collected and detected, and the demographic details, exposure status and PEP of rabies patients were obtained in 2005 and 2006 in Guangxi, Hunan and Guizhou provinces.ResultsThe results showed 19,806 human rabies cases were reported in China from 1996 to 2008, with an average of 1,524 cases each year, and the incidence almost was rising rapidly, with the peak in 2007 (3,300 cases). It was notable that nearly 50% of the total rabies cases nationwide were reported in Guangxi, Hunan and Guizhou provinces. In these three provinces, the rabies infection rate in dogs was 2.3%, and 60% investigated cities had a dog vaccination rate of below 70%; among the 315 recorded human cases, 66.3% did not receive any PEP at all, 27.6% received inadequate PEP, and only 6.0% received a full regime of PEP.ConclusionsIn recent years, rabies is reemerging and becoming a major public-health problem in China. Our analysis showed that unsuccessful control of dog rabies and inadequate PEP of patients were the main factors leading to the high incidence of human rabies in China, then there are following suggestions: (1) Strict control of free-ranging dogs and mandatory rabies vaccination should be enforced. (2)Establishing national animal rabies surveillance network is imperative. (3) PEP should be decided to initiate or withhold according to postmortem diagnosis of the biting animal. (4) The cost of PEP should be decreased or free, especially in rural areas. (5)Education of the public and health care staff should be enhanced.

O.460 Relevance of primary treatment of dog bite injuries in children

Thailand is a canine rabies endemic country with an annual prevalence above 1000 reported animals diagnosed rabid [1]. Over 345,000 humans are treated for possible rabies exposures annually [2]. Lack of perception of the disease burden, social, cultural and traditional beliefs play an important role in the failure of canine rabies control. It is unfortunate that health care budgets are increasingly allocated to human post-exposure treatment rather than to the eradication of rabies in the canine animal vector. Children under the age of 15 years represent up to one-half of dog bite victims and of human rabies deaths, but accurate data of dog bite prevalence are not available [3], [4], [5], [6]. Large scale pre-exposure immunization of children has been advocated but financial and logistic barriers have hindered implementation. This study analyzes direct medical costs of pre-exposure vaccination (PREP) as a human rabies preventive strategy, against the cost of post-exposure prophylaxis (PEP) in Thai children. Three pre- and post-exposure vaccine regimens are in use and this impacts on cost calculations. It was found that costs of both strategies, PREP of children or PEP of exposed, become equal when the dog bite incidence is 2–30%; depending on which post-exposure treatment regimens (PEP) are used.

Comparison of Safety and Immunogenicity of Purified Chick Embryo Cell Rabies Vaccine (PCECV) and Purified Vero Cell Rabies Vaccine (PVRV) Using the Thai Red Cross Intradermal Regimen at a Dose of 0.1 ML

Intradermal (ID) vaccination with modern cell culture rabies vaccines is a means to significantly reduce the cost of post-exposure prophylaxis as compared to intramuscular vaccination. In this study we evaluated the efficacy, immunogenicity and tolerability of PCECV and PVRV administered ID in doses of 0.1 mL per site according to the 2-site Thai Red Cross (TRC) regimen. Patients with WHO category III exposure to suspect or laboratory proven rabid animals were administered either PCECV (n=58) or PVRV (n=52) ID at a dose of 0.1 mL per site on days 0, 3 and 7 and at one site on days 30 and 90. Serum samples were withdrawn on days 0, 14, 30, 90, and 180 and rabies virus neutralizing antibody (RVNA) titers were determined by rapid fluorescent focus inhibition test (RFFIT). Patients who were exposed to laboratory confirmed rabid animals were followed up for one year after exposure. All 110 patients developed RVNA titers above 0.5 IU/mL by day 14. Adequate titers >0.5 IU/mL were maintained up to day 180. Both vaccines induced equivalent RVNA titers at all time points and were well tolerated. Five subjects who were bitten by laboratory confirmed rabid dogs were alive and healthy one year after exposure. As demonstrated, PCECV and PVRV are both immunogenic, efficacious and well tolerated when administered in the TRC post-exposure prophylaxis regimen in ID doses of 0.1 mL as recommended by WHO guidelines. The use of PCECV in this regimen may prove more economical in developing countries like India.

Cost-effectiveness of HIV post-exposure prophylaxis in France

To assess the cost-effectiveness of HIV post-exposure prophylaxis (PEP) in France. We used a decision tree to evaluate, from a society's perspective, the cost of PEP per quality-adjusted life-year (QALY) saved. We used 1999-2003 PEP surveillance data and literature-derived data on per event transmission probabilities, PEP efficacy and quality of life with HIV. HIV prevalence and lifetime cost of HIV/AIDS management in the HAART era were derived from French studies. We assumed that mean life expectancy in full health was 65 years among uninfected individuals and that the mean survival time after HIV infection was 22.5 years. The costs of PEP drugs and follow-up were derived from the French public sector. A 3% annual rate was used to discount future costs and effects. During 1999-2003, PEP was prescribed to 8958 individuals (heterosexual sex: 47.6%; homosexual sex: 28.4%; occupational exposure: 23.4%; drug injection: 0.6%); of those, 2143 were exposed to a known HIV-infected source. PEP was estimated to prevent 7.7 infections and saved 64.5 QALY at a net cost of euro 5.7 million, resulting in an overall cost-effectiveness ratio of euro 88,692 per QALY saved. PEP was cost saving for 4.4% of cases and cost effective (< euro 50,000 per QALY) in a further 11.3% of cases. In contrast, 72 and 52% of prescriptions had a cost-effectiveness ratio exceeding euro 200,000 and euro 2 millions, respectively, per QALY saved. Overall, the French PEP programme is only moderately cost effective. PEP guidelines should be revised to target high-risk exposures better.

Postexposure Chemoprophylaxis for Occupational Exposure to Human Immunodeficiency Virus in Traveling Health Care Workers

There has been little research on the use of human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) for occupational exposure in traveling health care workers (HCWs). Although PEP is the standard of care for occupational exposure to HIV in the United States, in third-world countries such medications are often unavailable and risks to the HCW may be higher. The aims of this study were to assess the incidence and types of blood and body fluid exposure and subsequent use of PEP in traveling HCWs seen at a large travel clinic prior to travel. To determine the utility of PEP, we retrospectively evaluated all HCWs presenting for counseling prior to travel for health care delivery. All employees who were seen at the Mayo Travel and Tropical Medicine Clinic from 1999 until July 2002 were included. Analysis was conducted via a chart review as well as an approved questionnaire mailed to all employees still at the Mayo Clinic. Eighty-six HCWs were included in the analysis, and 58 responded to the questionnaire. Of the 86 HCWs reviewed, 55 (64%) were determined to be at high risk for occupational exposure to HIV. Seventy-eight percent of the high-risk HCWs were documented to have been counseled about needlestick avoidance, and 55% brought PEP with them. In the 58 HCWs who returned the questionnaire, there were no reported deep needlesticks. One of the 39 high-risk HCWs who returned the questionnaire (2.6%) had a superficial needle exposure, but the source patient had pretested negative for HIV and therefore the HCW did not use PEP. Nine of the 39 (23%) had a blood splash onto intact skin, and one of these involved a large volume. This source patient also had pretested negative for HIV. None of the HCWs exposed to blood splash took PEP. Two HCWs (5.1%) at high risk had an exposure that would have required PEP if the source patient had not been pretested. Needlestick exposure and HIV PEP counseling is important for HCWs traveling for health care delivery. Exposure risks appear low but high enough to warrant supplying high-risk HCWs with PEP. HCWs are able to use the recommendations appropriately. Pretesting of surgical patients decreases the likelihood of starting PEP. Carrying a common supply of PEP for a larger group can decrease the cost of PEP.

Rabies post-exposure prophylaxis vaccination with purified chick embryo cell vaccine (PCECV) and purified vero cell rabies vaccine (PVRV) in a four-site intradermal schedule (4-0-2-0-1-1): An immunogenic, cost-effective and practical regimen

Currently, two intradermal (ID) regimens for rabies post-exposure prophylaxis (PEP) are recommended by WHO and used in countries where approved by national authorities: the Thai Red Cross (TRC) two-site ID regimen and the eight-site ID regimen. Besides these WHO recommended schedules, a new economical four-site ID regimen was evaluated that reduces the cost of PEP by up to 80%, when compared with the standard intramuscular Essen regimen, reduces the number of visits required for the patients when compared with the TRC regimen, and is more convenient than the eight-site regimen. To determine the immunogenicity of the ID four-site PEP regimen (4-0-2-0-1-1), 180 healthy volunteers were randomized to receive 0.1 mL volumes of PCECV or PVRV administered ID over both left and right shoulders and both deltoid regions on day 0, both deltoid regions on day 7 and over one deltoid region on days 30 and 90. Regardless of the vaccine, every subject developed rabies virus neutralizing antibody (RVNA) titers above 0.5 IU/mL by day 14, as determined by rapid fluorescent focus inhibition test (RFFIT) using a homologous test system. Two weeks after the last dose of vaccine, RVNA titers were all above 0.5 IU/mL (day 104). Geometric mean titers were similar throughout the study period. Both vaccines were well tolerated. These results demonstrate that a new four-site ID PEP regimen is a cost-effective and convenient alternative to IM (Essen or Zagreb) or ID (TRC or eight-site) regimens, especially using a 1 mL vial of vaccine (PCECV).

Cost comparison of rabies pre-exposure vaccination with post-exposure treatment in Thai children

Thailand is a canine rabies endemic country with an annual prevalence above 1000 reported animals diagnosed rabid [1]. Over 345,000 humans are treated for possible rabies exposures annually [2]. Lack of perception of the disease burden, social, cultural and traditional beliefs play an important role in the failure of canine rabies control. It is unfortunate that health care budgets are increasingly allocated to human post-exposure treatment rather than to the eradication of rabies in the canine animal vector. Children under the age of 15 years represent up to one-half of dog bite victims and of human rabies deaths, but accurate data of dog bite prevalence are not available [3–6]. Large scale pre-exposure immunization of children has been advocated but financial and logistic barriers have hindered implementation. This study analyzes direct medical costs of pre-exposure vaccination (PREP) as a human rabies preventive strategy, against the cost of post-exposure prophylaxis (PEP) in Thai children. Three pre- and post-exposure vaccine regimens are in use and this impacts on cost calculations. It was found that costs of both strategies, PREP of children or PEP of exposed, become equal when the dog bite incidence is 2–30%; depending on which post-exposure treatment regimens (PEP) are used.

Usefulness of a Rapid Human Immunodeficiency Virus-1 Antibody Test for the Management of Occupational Exposure to Blood and Body Fluid

To describe the usefulness of the OraQuick Rapid HIV-1 Antibody Test (OraSure Technologies, Bethlehem, PA) in cases of occupational exposure regarding its use with source-patient sera, effects on post-exposure prophylaxis (PEP) use, potential cost savings, and effects on healthcare worker (HCW) stress reaction symptoms. Before-and-after analysis. A 269-bed, tertiary-care medical center with adjacent clinics. All source-patients and HCWs experiencing an occupational exposure during the study period. Use of the OraQuick test with patient sera was validated prior to its use for occupational exposures. Exposures from January 1 through July 10, 2003 (enzyme immunoassay [EIA] group) and July 11 through December 31, 2003 (OraQuick group) were retrospectively reviewed and the use and cost of PEP was compared for each group. Randomly selected HCWs from both groups completed a survey to assess their stress reaction symptoms. After exclusion, there were 71 exposures in the EIA group and 79 in the OraQuick group. OraQuick results were 100% concordant with the reference standard of EIA and Western blot using patient sera. The mean number of doses ingested per course of PEP was significantly higher for HCWs in the EIA group (3.8; range, 0 to 6) compared with the OraQuick group (1.2; range, 0 to 3; P = .016). Cost analysis revealed a mean savings of dollar 6.62 with the OraQuick test per occupational exposure. Although the survey failed to detect an overall reduction in HCW stress reaction symptoms using OraQuick for source-patient testing, 11 HCWs in the EIA group had repetitive thoughts of the exposure compared with 5 in the OraQuick group (P = .049). Because of the reduction in ingested doses of unnecessary PEP and reduced cost of occupational exposure management with their use, rapid HIV-antibody tests should be the preferred method for source-patient testing following an occupational exposure.

Value of skin testing for predicting reactions to equine rabies immune globulin.

The high cost of postexposure prophylaxis for rabies is one reason that treatment is inadequate in developing countries. This problem has kindled interest in the use of equine rabies immune globulin, which is a less expensive, yet effective, substitute for human rabies immune globulin. Fatal anaphylaxis is a feared complication of the administration of heterologous serum; therefore, authoritative sources recommend prior skin testing. However, recommendations for methods of administering such a skin test and for its interpretation vary greatly. We embarked on a long-term study to develop guidelines for administration and interpretation of skin test results and to eventually determine a cost-benefit ratio. The skin test is not predictive of serum sickness. Anaphylaxis is rare with modern purified and pepsin-digested equine rabies immune globulins. We consider a skin test to be positive only if a wheal of > 10 mm in diameter, with or without flare, or a wheal of 5-10 mm in diameter with a flare of > 20 mm develops. Long-term studies will be required to answer the remaining questions regarding test criteria and cost benefits.