Rabies vaccination strategies in a western country: a cost evaluation

Introduction

Rabies is a fatal but preventable infectious disease with a large disease burden in endemic countries. The risk of contracting rabies for travellers from a Western country is low. However, an increasing number of Dutch travellers, potentially exposed to rabies abroad, consult a clinician for post-exposure prophylaxis. In this study, several interventions were examined on how they might influence costs involved in rabies treatment and prevention, including the most recent vaccination guidelines and the use of intradermal vaccination.

Methods

A decision tree based economic model was constructed. Costs of new versus old guidelines, intramuscular versus intradermal vaccination, and post-exposure treatment subsequent to increased vaccination coverage in several risk groups were calculated and compared to each other. Statistical uncertainty with respect to numbers of travellers and vaccination coverage was assessed.

Results

Costs were highest using the old guidelines, estimated at €15.1 million (€405 per vaccinated person). Intradermal vaccinations in combination with the new guidelines led to the lowest costs, estimated at €10.1 million (€270 per vaccinated person). A higher vaccination uptake resulted in higher overall costs. The ratio between the additional vaccinated persons and additional costs in all risk groups was similar, around €104 per person.

Conclusions

The new rabies vaccination guidelines reduced total costs. Strategies with increased vaccination uptake led to fewer rabies immunoglobulin administrations and fewer vaccinations after exposure but at higher total costs. Although intradermal administration of rabies vaccination on a large scale can reduce total costs of pre-exposure prophylaxis and can positively influence vaccination uptake, it remains a costly intervention.

Key messages

The new vaccination guidelines reduce total costs of rabies prevention. Intradermal administration of rabies vaccination on a large scale can further reduce total costs of pre-exposure prophylaxis. Strategies with increased vaccination uptake lead to fewer rabies immunoglobulin administrations and fewer vaccinations after exposure but at higher total costs.

Endoscopic mucosal resection (EMR) versus endoscopic submucosal dissection (ESD) for resection of large distal non-pedunculated colorectal adenomas (MATILDA-trial): rationale and design of a multicenter randomized clinical trial

Background

Endoscopic mucosal resection (EMR) is currently the most used technique for resection of large distal colorectal polyps. However, in large lesions EMR can often only be performed in a piecemeal fashion resulting in relatively low radical (R0)-resection rates and high recurrence rates. Endoscopic submucosal dissection (ESD) is a newer procedure that is more difficult resulting in a longer procedural time, but is promising due to the high en-bloc resection rates and the very low recurrence rates. We aim to evaluate the (cost-)effectiveness of ESD against EMR on both short (i.e. 6 months) and long-term (i.e. 36 months). We hypothesize that in the short-run ESD is more time consuming resulting in higher healthcare costs, but is (cost-) effective on the long-term due to lower patients burden, a higher number of R0-resections and lower recurrence rates with less need for repeated procedures.

Methods

This is a multicenter randomized clinical trial in patients with a non-pedunculated polyp larger than 20 mm in the rectum, sigmoid, or descending colon suspected to be an adenoma by means of endoscopic assessment. Primary endpoint is recurrence rate at follow-up colonoscopy at 6 months. Secondary endpoints are R0-resection rate, perceived burden and quality of life, healthcare resources utilization and costs, surgical referral rate, complication rate and recurrence rate at 36 months. Quality-adjusted-life-year (QALY) will be estimated taking an area under the curve approach and using EQ-5D-indexes. Healthcare costs will be calculated by multiplying used healthcare services with unit prices. The cost-effectiveness of ESD against EMR will be expressed as incremental cost-effectiveness ratios (ICER) showing additional costs per recurrence free patient and as ICER showing additional costs per QALY.

Discussion

If this trial confirms ESD to be favorable on the long-term, the burden of extra colonoscopies and repeated procedures can be prevented for future patients.

Trial registration

NCT02657044 (Clinicaltrials.gov), registered January 8, 2016.

Smoking is Associated With Extra-intestinal Manifestations in Inflammatory Bowel Disease

BACKGROUND AND AIMS

Smoking affects the course of disease in patients with ulcerative colitis (UC) and Crohn's disease (CD). We aimed to study the association between smoking and extra-intestinal manifestations (EIMs) in inflammatory bowel disease (IBD).

METHODS

We cross-sectionally explored the association between smoking and EIMs in IBD in three cohort studies: (1) the COIN study, designed to estimate healthcare expenditures in IBD; (2) the Groningen study, focused on cigarette smoke exposure and disease behaviour in IBD; and (3) the JOINT study, evaluating joint and back manifestations in IBD.

RESULTS

In the COIN, Groningen and JOINT cohorts, 3030, 797 and 225 patients were enrolled, of whom 16, 24 and 23.5% were current smokers, respectively. Chronic skin disorders and joint manifestations were more prevalent in smoking IBD patients than in non-smokers (COIN, 39.1 vs 29.8%, p <0.01; Groningen, 41.7 vs 30.0%, p <0.01) in both CD and UC. In the JOINT cohort, smoking was more prevalent in IBD patients with joint manifestations than in those without (30.3 vs 13.0%, p <0.01). EIMs appeared to be more prevalent in high- than in low-exposure smokers (56.0 vs 37.1%, p = 0.10). After smoking cessation, the prevalence of EIMs in IBD patients rapidly decreased towards levels found in never smokers (lag time: COIN cohort, 1-2 years; Groningen cohort, within 1 year).

CONCLUSIONS

There is a robust dose-dependent association between active smoking and EIMs in both CD and UC patients. Smoking cessation was found to result in a rapid reduction of EIM prevalence to levels encountered in never smokers.

Simulated epidemiological and economic effects of measures to reduce piglet supply during a classical swine fever epidemic in the Netherlands

The effects of additional measures adopted during a classical swine fever (CSF) epidemic to reduce piglet supply, namely, an insemination ban, abortion of sows and killing of young piglets, are studied using a stochastic, spatial, dynamic epidemiological simulation model of the pig sector in The Netherlands. The piglet supply derived from the epidemiological model is used as input for a sector-level market and trade model that simulates the pig market in The Netherlands. Changes in the economic welfare of different stakeholders are measured, as is the net welfare effect for the economy in The Netherlands. Sensitivity analysis is performed on parameters such as destruction capacity constraints and the duration of the high-risk period. Additional measures to reduce piglet supply are found to have no epidemiological impact, but they do involve larger economic welfare changes for stakeholders and a larger net welfare loss for the economy in The Netherlands. These findings do not support the use of the additional measures. Moreover, sensitivity analysis shows that such measures do not solve the problem of a shortage in rendering capacities.