title: Cost-effectiveness comparison of response strategies to a large-scale anthrax attack on the chicago metropolitan area: impact of timing and surge capacity.
abstract: 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.
authors: 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. d-kyriacou@northwestern.edu
authors: Demetrios N
authors: DN
authors: Kyriacou
authors: Debra
authors: D
authors: Dobrez
authors: Jorge P
authors: JP
authors: Parada
authors: Justin M
authors: JM
authors: Steinberg
authors: Adam
authors: A
authors: Kahn
authors: Charles L
authors: CL
authors: Bennett
authors: Brian P
authors: BP
authors: Schmitt
mesh_terms: D000881:Anthrax / Q000188:drug therapy* / Q000191:economics* / Q000517:prevention & control; D022122:Anthrax Vaccines / Q000008:administration & dosage / Q000191:economics*; D019072:Antibiotic Prophylaxis / Q000191:economics* / Q000706:statistics & numerical data; D001408:Bacillus anthracis; D055885:Biohazard Release; D023482:Bioterrorism / Q000191:economics* / Q000517:prevention & control / Q000706:statistics & numerical data; D002641:Chicago; D003362:Cost-Benefit Analysis; D004632:Emergency Medical Services / Q000191:economics; D006801:Humans; D013997:Time Factors; D014611:Vaccination / Q000191:economics* / Q000706:statistics & numerical data
chemical_list: D022122:Anthrax Vaccines