title: 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.
abstract: BACKGROUND
  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.
  
  
  METHODS
  A cost-effectiveness analysis in metropolitan France using a decision-tree model and input data from 2001 to 2011.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
authors: 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. Electronic address: fribadeaudumas@gmail.com.
authors: Florence
authors: F
authors: Ribadeau Dumas
authors: 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.
authors: Dieynaba S
authors: DS
authors: N'Diaye
authors: Univ Pierre et Marie Curie, Cellule Pasteur UPMC, F-75015, Paris, France; Institut Pasteur, Unité d'Epidémiologie des Maladies Emergentes, F-75015, Paris, France.
authors: Juliette
authors: J
authors: Paireau
authors: Assistance Publique Hôpitaux de Marseille, CHU Nord, Pôle Infectieux, Institut Hospitalo-Universitaire Méditerranée Infection, F-13015 Marseille, France; Aix Marseille Université, Unité de Recherche en Maladies Infectieuses et Tropicales Emergentes (URMITE), UM63, CNRS 7278, IRD 198, Inserm 1095, Faculté de Médecine, F-13005 Marseille, France.
authors: Philippe
authors: P
authors: Gautret
authors: Institut Pasteur, Unité Dynamique des lyssavirus et adaptation à l'hôte, National Reference Center for Rabies, F-75015 Paris, France.
authors: Hervé
authors: H
authors: Bourhy
authors: Université Paris Dauphine, LEDa/LEGOS, F-75016, Paris, France.
authors: Claude
authors: C
authors: Le Pen
authors: IAME, UMR 1137, INSERM, F-75018 Paris, France; AP-HP, Hôpital Bichat, Service de Maladies Infectieuses, F-75018 Paris, France; Univ Paris Diderot, Sorbonne Paris Cité, F-75018 Paris, France.
authors: Yazdan
authors: Y
authors: Yazdanpanah
mesh_terms: D000063:Accidents, Traffic / Q000401:mortality / Q000706:statistics & numerical data; D000818:Animals; D001733:Bites and Stings; D003362:Cost-Benefit Analysis; D003663:Decision Trees; D004285:Dogs; D005602:France; D006801:Humans; D056990:Post-Exposure Prophylaxis / Q000191:economics; D015995:Prevalence; D011818:Rabies / Q000401:mortality / Q000517:prevention & control*; D011819:Rabies Vaccines / Q000008:administration & dosage / Q000191:economics; D018570:Risk Assessment; D013997:Time Factors
chemical_list: D011819:Rabies Vaccines
keywords: Adverse event; Cost-effectiveness; Post-exposure prophylaxis; Rabies; Road accident