狂犬病暴露后预防在狂犬病风险极低情况下的成本效益：基于法国经验的决策树模型

Cost-effectiveness of rabies post-exposure prophylaxis in the context of very low rabies risk: A decision-tree model based on the experience of France.

作者信息

Ribadeau Dumas Florence, N'Diaye Dieynaba S, Paireau Juliette, Gautret Philippe, Bourhy Hervé, Le Pen Claude, Yazdanpanah Yazdan

机构信息

Université Paris Dauphine, LEDa/LEGOS, F-75016, Paris, France; Institut Pasteur, Unité Dynamique des lyssavirus et adaptation à l'hôte, National Reference Center for Rabies, F-75015 Paris, France; Institut Pasteur, CAR/CMIP/CINP, F-75015, Paris, France.

IAME, UMR 1137, INSERM, F-75018 Paris, France; UPMC Univ Paris 06, ED393, F-75005, Paris, France; Univ Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France.

出版信息

Vaccine. 2015 May 11;33(20):2367-78. doi: 10.1016/j.vaccine.2015.02.075. Epub 2015 Mar 20.

DOI:10.1016/j.vaccine.2015.02.075

PMID:25797366

Abstract

INTRODUCTION

Benefit-risk of different anti-rabies post-exposure prophylaxis (PEP) strategies after scratches or bites from dogs with unknown rabies status is unknown in very low rabies risk settings.

DESIGN AND SETTING

A cost-effectiveness analysis in metropolitan France using a decision-tree model and input data from 2001 to 2011.

POPULATION

A cohort of 2807 patients, based on the mean annual number of patients exposed to category CII (minor scratches) or CIII (transdermal bite) dog attacks in metropolitan France between 2001 and 2011.

INTERVENTIONS

Five PEP strategies: (A) no PEP for CII and CIII; (B) vaccine only for CIII; (C) vaccine for CII and CIII; (D) vaccine+ rabies immunoglobulin (RIG) only for CIII; and (E) vaccine for CII and vaccine+ RIG for CIII.

MAIN OUTCOMES MEASURES

The number of deaths related to rabies and to traffic accidents on the way to anti-rabies centers (ARC), effectiveness in terms of years of life gained by reducing rabies cases and avoiding traffic accidents, costs, and incremental cost-effectiveness ratios (ICER) associated with each strategy.

RESULTS

Strategy E led to the fewest rabies cases (3.6 × 10(-8)) and the highest costs (€ 1,606,000) but also to 1.7 × 10(-3) lethal traffic accidents. Strategy A was associated with the most rabies cases (4.8 × 10(-6)), but the risk of traffic accidents and costs were null; therefore, strategy A was the most effective and the least costly. The sensitivity analysis showed that, when the probability that a given dog is rabid a given day (PA) was > 1.4 × 10(-6), strategy D was more effective than strategy A; strategy B became cost-effective (i.e. ICER vs strategy A < 3 × French Gross Domestic Product per capita) when PA was > 1 .4 × 10(-4).

CONCLUSIONS

In the metropolitan France's very low rabies prevalence context, PEP with rabies vaccine, administered alone or with RIG, is associated with significant and unnecessary costs and unfavourable benefit-risk ratios regardless to exposure category.

摘要

引言

在狂犬病风险极低的环境中，对于被狂犬病状态不明的狗抓伤或咬伤后采用不同的狂犬病暴露后预防（PEP）策略的获益风险尚不清楚。

设计与背景

在法国大都市地区进行一项成本效益分析，使用决策树模型和2001年至2011年的输入数据。

研究对象

根据2001年至2011年法国大都市地区每年暴露于II级（轻微抓伤）或III级（穿透性咬伤）犬伤患者的平均数量，确定一组2807名患者。

干预措施

五种PEP策略：（A）II级和III级均不进行PEP；（B）仅对III级使用疫苗；（C）对II级和III级均使用疫苗；（D）仅对III级使用疫苗+狂犬病免疫球蛋白（RIG）；（E）对II级使用疫苗，对III级使用疫苗+RIG。

主要结局指标

与狂犬病相关的死亡人数以及前往狂犬病防治中心（ARC）途中的交通事故死亡人数、通过减少狂犬病病例和避免交通事故所获得的生命年数方面的有效性、成本以及与每种策略相关的增量成本效益比（ICER）。

结果

策略E导致的狂犬病病例最少（3.6×10⁻⁸）且成本最高（1,606,000欧元），但也导致1.7×10⁻³起致命交通事故。策略A与最多的狂犬病病例相关（4.8×10⁻⁶），但交通事故风险和成本为零；因此，策略A是最有效且成本最低的。敏感性分析表明，当某只狗在某一天患狂犬病的概率（PA）>1.4×10⁻⁶时，策略D比策略A更有效；当PA>1.4×10⁻⁴时，策略B具有成本效益（即与策略A相比，ICER<3×法国人均国内生产总值）。