Kyriacou Demetrios N, Dobrez Debra, Parada Jorge P, Steinberg Justin M, Kahn Adam, Bennett Charles L, Schmitt Brian P
Demetrios N. Kyriacou, MD, PhD, is Professor of Emergency Medicine and Preventive Medicine, Department of Emergency Medicine and Department of Preventive Medicine, University of South Carolina College of Pharmacy, Columbia, South Carolina, USA.
Biosecur Bioterror. 2012 Sep;10(3):264-79. doi: 10.1089/bsp.2011.0105. Epub 2012 Jul 30.
Rapid public health response to a large-scale anthrax attack would reduce overall morbidity and mortality. However, there is uncertainty about the optimal cost-effective response strategy based on timing of intervention, public health resources, and critical care facilities. We conducted a decision analytic study to compare response strategies to a theoretical large-scale anthrax attack on the Chicago metropolitan area beginning either Day 2 or Day 5 after the attack. These strategies correspond to the policy options set forth by the Anthrax Modeling Working Group for population-wide responses to a large-scale anthrax attack: (1) postattack antibiotic prophylaxis, (2) postattack antibiotic prophylaxis and vaccination, (3) preattack vaccination with postattack antibiotic prophylaxis, and (4) preattack vaccination with postattack antibiotic prophylaxis and vaccination. Outcomes were measured in costs, lives saved, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). We estimated that postattack antibiotic prophylaxis of all 1,390,000 anthrax-exposed people beginning on Day 2 after attack would result in 205,835 infected victims, 35,049 fulminant victims, and 28,612 deaths. Only 6,437 (18.5%) of the fulminant victims could be saved with the existing critical care facilities in the Chicago metropolitan area. Mortality would increase to 69,136 if the response strategy began on Day 5. Including postattack vaccination with antibiotic prophylaxis of all exposed people reduces mortality and is cost-effective for both Day 2 (ICER=$182/QALY) and Day 5 (ICER=$1,088/QALY) response strategies. Increasing ICU bed availability significantly reduces mortality for all response strategies. We conclude that postattack antibiotic prophylaxis and vaccination of all exposed people is the optimal cost-effective response strategy for a large-scale anthrax attack. Our findings support the US government's plan to provide antibiotic prophylaxis and vaccination for all exposed people within 48 hours of the recognition of a large-scale anthrax attack. Future policies should consider expanding critical care capacity to allow for the rescue of more victims.
对大规模炭疽攻击做出快速的公共卫生应对措施可降低总体发病率和死亡率。然而，基于干预时机、公共卫生资源和重症监护设施，关于最佳成本效益应对策略仍存在不确定性。我们开展了一项决策分析研究，以比较针对芝加哥大都市区理论上大规模炭疽攻击的应对策略，攻击分别始于攻击后第2天或第5天。这些策略对应于炭疽建模工作组为大规模炭疽攻击的全人群应对提出的政策选项：（1）攻击后抗生素预防，（2）攻击后抗生素预防和疫苗接种，（3）攻击前疫苗接种加攻击后抗生素预防，以及（4）攻击前疫苗接种加攻击后抗生素预防和疫苗接种。结果通过成本、挽救的生命、质量调整生命年（QALY）和增量成本效益比（ICER）来衡量。我们估计，攻击后第2天开始对所有139万名接触炭疽的人进行抗生素预防，将导致205,835名感染受害者、35,049名暴发性受害者和28,612人死亡。芝加哥大都市区现有的重症监护设施仅能挽救6,437名（18.5%）暴发性受害者。如果应对策略在第5天开始，死亡率将增至69,136人。对所有接触者进行攻击后抗生素预防并加用疫苗接种可降低死亡率，并且对于第2天（ICER = 182美元/QALY）和第5天（ICER = 1,088美元/QALY）的应对策略而言均具有成本效益。增加重症监护病床的可及性可显著降低所有应对策略的死亡率。我们得出结论，对所有接触者进行攻击后抗生素预防和疫苗接种是大规模炭疽攻击的最佳成本效益应对策略。我们的研究结果支持美国政府在确认大规模炭疽攻击后48小时内为所有接触者提供抗生素预防和疫苗接种的计划。未来的政策应考虑扩大重症监护能力，以便抢救更多受害者。
