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The 4-site intradermal rabies vaccine regimen requires only 3 clinic visits.

Posted by mwarrell on 15 Mar 2011 at 09:21 GMT

This analysis by Hampson and colleagues of the economy of rabies vaccine regimens is an important study, but the 4-site ID regimen is misrepresented as requiring 4 clinic visits.
The proposed 4-site ID regimen needs only 3 visits (as mentioned elsewhere including in ref. 36) and so if there is no sharing of vials, the maximum number used is 3 not 4. The interpretation of the results would be considerably altered by this change. Recalculation using the correct data would be very helpful to policy makers.

Secondly, a new user would want a simple comparison of the vaccine costs of the different methods. Would it therefore be possible to calculate the cost of vaccination (number of vials used) for different regimens according to the number of patients treated? This is not the same as fig 2 ‘Cost per rabies death averted’ which could vary in different places.

No competing interests declared.

RE: The 4-site intradermal rabies vaccine regimen requires only 3 clinic visits.

KHampson replied to mwarrell on 18 Mar 2011 at 11:56 GMT

Our study provides a framework for evaluating the cost-effectiveness of different regimens and the expected vial use of those regimens in different throughput clinics from the perspective of health providers and bite victims in order to inform policy decisions. Assuming the 4-site regimen can be effectively delivered from 3 rather than 4 clinic visits (i.e. d0: 4 x 0.1mL injections or a single 0.5mL vial divided between 4 sites, d7: 2 x 0.1mL injections, d28: 1 x 0.1mL injection) as proposed in ref. 36 means that the 4-site regimen would use less vaccine and become more cost-effective.

We have therefore calculated the cost-effectiveness per rabies death averted for the 3-visit 4-site regimen using the parameter values and methods described in the main text (i.e. based on the costs described in Table 2, and the probability of 0.19 that rabies-exposed bite victims develop rabies in the absence of PEP as per ref 19). In the attached note we compare the cost-effectiveness of the proposed 3-visit 4-site regimen with other regimens in Figure 1, but note that absolute cost-effectiveness varies with locale-specific costs. As suggested, a more intuitive comparison for health practitioners is vial use (thus relative costs to health care providers). Vial use for the 3-visit schedule of the 4-site ID regimen is compared to other PEP vaccination regimens in Figure 2 of the attached note. A comparison of the different regimens in terms of their cost to patients is also presented in Table 1 of the attached note.

These analyses imply that evaluation of the 4-site ID regimen using a 3-visit schedule is warranted by WHO, as this could be highly cost-effective for health practitioners and would reduce both indirect (travel and accommodation) and direct (PEP) costs for bite victims. In particular, curtailing the schedule to just 3 visits means that fewer vials would be opened and discarded in lower throughput clinics resulting in greater savings.

As per WHO requirements, clinical data from the administration of the 3-visit schedule for the 4-site regimen would need to be evaluated by WHO in order to include this regimen in their recommendations for its future use. These analyses suggest that clinical trials for this should be a research priority for effective translation to policy.

No competing interests declared.

RE: RE: The 4-site intradermal rabies vaccine regimen requires only 3 clinic visits.

KHampson replied to KHampson on 22 Mar 2011 at 08:25 GMT

The following pdf is an accompaniment to the comment above:

No competing interests declared.