A Cost-Effectiveness Analysis of Pre-Exposure Prophylaxis to Avert Rabies Deaths in School-Aged Children in India

Abstract

Children contribute to one-half of the total painful rabies mortalities in India. The state-of-the-art rabies mortality averting strategies need exploration for the effective implementation of pre-exposure prophylaxis (PrEP) in India. This study reports on the economic evaluation of various PrEP and post-exposure prophylaxis (PEP) strategies to avert rabies mortalities in school-aged children in India. A decision tree model has been developed for children in the age group of 5–15 years to evaluate various PrEP + PEP and PEP only regimens. The 2-site intradermal regimen administered on day zero and seven was chosen as the intervention [PrEP (I)]. ICER was calculated from the quasi-societal and quasi-health systems’ perspectives for the base case analysis, along with one-way sensitivity, and scenario analyses for each regimen. The incremental DALYs averted per million population with the implementation of PrEP (I) ranged between 451 and 85,069 in 2020. The ICER was reported in the range of USD 384–352/DALY averted (non-dominant) in comparison to PEP regimens from a quasi-societal perspective. PrEP (I) is reported to be ‘very cost effective’ in comparison with PEP regimens from the quasi-societal and quasi-health systems’ perspectives and reduce deaths by up to 89.9%. This study concludes that the PrEP (I) regimen is a cost-effective and life-saving strategy to avert painful mortalities due to rabies in school-aged children in India.

Is Pre-Exposure Prophylaxis a Cost-Effective Intervention to Avert Rabies Deaths among School-Aged Children in India? Comment on Royal et al. A Cost-Effectiveness Analysis of Pre-Exposure Prophylaxis to Avert Rabies Deaths in School-Aged Children in India. Vaccines 2023, 11, 88

“…I read with interest the article “A Cost-Effectiveness Analysis of Pre-Exposure Prophylaxis to Avert Rabies Deaths in School-Aged Children in India” by Royal et al, recently published in Vaccines [ 1 ].…”

“…To this end, Royal and colleagues developed a decision-tree model to assess the cost-effectiveness of several pre-exposure (PrEP) and post-exposure prophylaxis (PEP) strategies to avert rabies mortalities in school-aged (5–15-year-old) children in India [ 1 ].…”

“…The results of their analyses suggest that a two-site intradermal PrEP regimen administered on days zero and seven is “very cost effective”, as opposed to eight comparator regimens, with up to 89.9% fewer deaths resulting from the implementation of the proposed PrEP intervention over the standard of care, per the national guidelines. Based on incremental costs, the authors conclude that PrEP is a cost-effective intervention and will reduce rabies-associated mortality and morbidity in the more than 230 million at-risk school-aged children in India [ 1 ].…”

“…recorded fewer than 1 death per million in 2019 [ 5 ]; and a recent study based on data from the Global Burden of Diseases (GBD) 2019 survey estimated ~4 deaths per million [ 4 ]. In stark contrast, the model developed by Royal et al predicted that their favored PrEP regimen (pre-exposure prophylaxis plus post-exposure prophylaxis, per the WHO guidelines) would result in 273 deaths per million of the population (see Table 3, in [ 1 ]). This is an order of magnitude greater the estimated annual rabies deaths per the WHO and exceeds by three or more orders of magnitude the Govt.…”

“…of India’s estimates. Of perhaps greater concern, the Royal model predicts that comparator post-exposure prophylaxis-only regimens that include the current standard of care would result in, on average, greater than 2500 deaths per million [ 1 ]. If accurate, this extraordinarily large number of predicted rabies deaths would not only be multiple orders of magnitude above the current independent estimates of rabies mortality in India, but would implausibly be twice as large as the annual sum of deaths resulting from all other communicable diseases across all age groups in the nation [ 5 ].…”