Naficy A, Rao M R, Paquet C, Antona D, Sorkin A, Clemens J D
National Institute of Child Health and Human Development, Bethesda, Md 20892, USA.
JAMA. 1998 Feb 18;279(7):521-5. doi: 10.1001/jama.279.7.521.
There is significant controversy about how best to control cholera epidemics in refugee settings. Specifically, there is marked disagreement about whether to use oral cholera vaccines in these settings, despite the improved safety and effectiveness profiles of these vaccines.
To determine the cost-effectiveness of alternative intervention strategies, including vaccination, to control cholera outbreaks in sub-Saharan refugee camps.
A cost-effectiveness analysis based on probabilities of cholera outcomes derived from epidemiologic data compiled for refugee settings in Malawi from 1987 through 1993; data for costs were obtained from a large relief agency that provides medical care in such settings.
A hypothetical refugee camp with 50000 persons in sub-Saharan Africa evaluated for a 2-year period.
We compared the costs and outcomes of alternative strategies in which appropriate rehydration therapy for cholera is introduced preemptively (at the establishment of a camp) or reactively (once an epidemic is recognized) and in which mass immunization with oral B subunit killed whole-cell (BS-WC) cholera vaccine is added to a rehydration program either preemptively or reactively.
Cost per cholera case prevented and cost per cholera death averted.
In a situation with no available rehydration therapy suitable for the management of severe cholera, a strategy of preemptive therapy ($320 per death averted) costs less and is more effective than a strategy of reactive therapy ($586 per death averted). Adding vaccination to preemptive therapy is expensive: $1745 per additional death averted for preemptive vaccination and $3833 per additional death averted for reactive vaccination. However, if the cost of vaccine falls below $0.22 per dose, strategies combining vaccination and preemptive therapy become more cost-effective than therapy alone.
Provision for managing cholera outbreaks at the inception of a refugee camp (preemptive therapy) is the most cost-effective strategy for controlling cholera outbreaks in sub-Saharan refugee settings. Should the price of BS-WC cholera vaccine fall below $0.22 per dose, however, supplementation of preemptive therapy with mass vaccination will become a cost-effective option.
在难民环境中如何最好地控制霍乱疫情存在重大争议。具体而言，尽管口服霍乱疫苗的安全性和有效性有所提高，但对于在这些环境中是否使用该疫苗仍存在明显分歧。
确定包括疫苗接种在内的替代干预策略在撒哈拉以南难民营控制霍乱疫情的成本效益。
基于1987年至1993年马拉维难民环境中收集的流行病学数据得出的霍乱结局概率进行成本效益分析；成本数据来自在这种环境中提供医疗服务的大型救援机构。
对撒哈拉以南非洲一个有50000人的假设难民营进行为期2年的评估。
我们比较了替代策略的成本和结局，其中霍乱的适当补液疗法是预先（在难民营建立时）或反应性（一旦确认疫情）引入的，并且口服B亚单位全细胞灭活（BS-WC）霍乱疫苗的大规模免疫是预先或反应性地添加到补液计划中的。
预防每例霍乱病例的成本和避免每例霍乱死亡的成本。
在没有适用于严重霍乱管理的补液疗法的情况下，预先治疗策略（每避免一例死亡320美元）比反应性治疗策略（每避免一例死亡586美元）成本更低且更有效。在预先治疗中添加疫苗接种成本高昂：预先接种疫苗每额外避免一例死亡需1745美元，反应性接种疫苗每额外避免一例死亡需3833美元。然而，如果疫苗成本降至每剂0.22美元以下，将疫苗接种与预先治疗相结合的策略将比单独治疗更具成本效益。
在难民营设立之初提供霍乱疫情管理（预先治疗）是撒哈拉以南难民环境中控制霍乱疫情最具成本效益的策略。然而，如果BS-WC霍乱疫苗价格降至每剂0.22美元以下，用大规模疫苗接种补充预先治疗将成为一种具有成本效益的选择。
