A decision-analytic approach to postexposure rabies prophylaxis

Developing and evaluating an intervention to improve care and reduce costs of rabies postexposure therapy: an observational quality improvement initiative in selected vaccination units in Sri Lanka

BACKGROUND

Exposure to the rabies virus is fatal unless a patient is treated with a timely, accurate and complete administration of postexposure prophylaxis (PEP). The level of adherence to PEP guidelines by health service providers is therefore critical in providing high-quality care as well as preventing unnecessary costs.

METHODS

We developed a simple user-friendly decision aid based on Sri Lankan national guidelines for the administration of PEP and trialed it over a 5-month period in three study settings. Pre and post levels of adherence to the national guidelines by service providers was measured in each setting. Changes to per patient cost for rabies medications and hospital admissions were also collected.

RESULTS

A significant improvement in adherence to the guidelines was observed in two settings with a nonsignificant improvement observed in the third setting. We estimated a total cost saving of LKR 158 476 across the three sites, comprising LKR 14 418 in admissions cost savings and LKR 144 058 in medication savings.

CONCLUSION

We conclude that the development of a decision aid for the administration of PEP is likely to be an effective and cost-saving intervention in the Sri Lankan setting. Further research is required to inform the generalizability of our findings.

A review of the economics of the prevention and control of rabies. Part 1: Global impact and rabies in humans

The existing literature on the economics of rabies and its control can be characterised as a poorly documented set of cost estimates with insufficient information to allow replication of the analyses. Most articles have numerous 'violations' of the standard recommended procedures for assessing the burden of disease and the cost and benefits of interventions. Per capita costs are often crudely extrapolated from small to large populations without allowing for geographic differences in incidence. Furthermore, most studies do not distinguish between financial charges and true economic costs, and only a few articles contain a multiyear framework, complete with discounting of future costs and benefits. With the exception of the increase in average incidence of postexposure prophylaxes (PEPs) in Asia, the average incidences of both human-rabies cases and PEPs in Africa, the Americas and Europe have not changed significantly over time. There are, however, large differences between countries within a region and regional averages can conceal notable changes in incidences over time for a given country. The largest number of human-rabies cases occur in developing countries due to the low levels of vaccination among dogs, the high cost of biologicals for PEP and problems of availability. The costs (1995 values) of PEP range from $US1707 per person in Massachusetts, US, to $US2.50 for a complete series of vaccinations (without immunoglobulin) using sheep-derived vaccines in Karachi, Pakistan. Most studies which reported the cost of PEP, however, provided only direct medical costs and did not consider indirect costs such as lost productivity due to death, permanent disability or time spent while receiving medical care. Given the expense of controlling rabies in dogs and wildlife, there is an urgent need to develop a cheaper human-rabies vaccine or further refine the 'low-dose' PEP regimes. PEP is often given unnecessarily, and experience with expert consultations systems and algorithms has shown that the rate, and therefore total cost, of PEP can be significantly reduced. However, because it may be difficult to identify lesions from a bite by a bat, algorithms may be of less value when dealing with possible exposure to bat rabies. Using US prices and values, only 2 individuals per 1000 possible contacts have to be at risk from bat rabies in order for it to be economically justifiable to give PEP to all those potentially exposed to bat rabies. With regard to pre-exposure vaccination, routine use of pre-exposure has generally not been shown to be cost effective.

Dog bites in Bosnia

BACKGROUND

Rabies is a zoonosis that remains endemic in most parts of the world. Primary care physicians are in the first line of defence against the disease. An increasing number of British practitioners and medical students are being exposed to the dangers of rabies through humanitarian work on overseas attachments. Rabies is enzootic throughout Bosnia-Herzegovina and presents a hazard to the multinational troops currently deployed there.

AIM

To describe the British Army's experience of animal bites and rabies prevention in Bosnia during the first six months of its current peace enforcement mission, and to make general recommendations on the good management of any rabies hazard at primary care level and under field conditions.

METHODS

Routine data from the Army's epidemiological database (ARRC 97) were reviewed, and theatre issues of rabies vaccine and immune globulin were used as a proxy measure for administered post-exposure prophylaxis.

RESULTS

A total of 62 animal bites were reported in British troops between December 1995 and May 1996, of which 28 were unprovoked bites and resulted in the administration of a course of rabies vaccine. Ten of these were severe bites and rabies immune globulin (RIG) was administered in addition. The total cost of rabies post-exposure prophylaxis was US$6914.00.

CONCLUSION

The prevention of rabies has major human and resource implications, and primary care staff involved in rabies post-exposure management need to be well supported in their clinical decision-making. Rabies protocols should be clear and unambiguous. The effective medical surveillance of military or humanitarian missions in rabies-enzootic areas must include the prompt reporting of animal bites. The predeployment training of medical teams should include an up-to-date assessment of the local rabies threat.

The importance of patient preferences for comorbidities in cost-effectiveness analyses

When using cost-effectiveness analyses to prioritize the allocation of health care resources across patients, a standard definition of effectiveness must be used. In an informal review of cost-effectiveness analyses, we found a heterogeneity in the methods used to qualify adjust years of life. Many studies do not account for the morbid conditions that patients experience other than the index condition being studied. These studies systematically overstate health benefit relative to studies that do for comorbidities. We recommend that patient preferences for comorbid conditions be incorporated into analyses to allow a consistent and facile comparison of cost-utility ratios for societal decision making.