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Cost-Effectiveness of Defending against Bioterrorism: A Comparison of Vaccination and Antibiotic Prophylaxis against Anthrax

Robert A. Fowler, MD, MS; Gillian D. Sanders, PhD; Dena M. Bravata, MD, MS; Bahman Nouri, MD; Jason M. Gastwirth, MBA; Dane Peterson, MBA; Allison G. Broker, MBA; Alan M. Garber, MD, PhD; and Douglas K. Owens, MD, MS
[+] Article and Author Information

From Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Duke University, Duke Clinical Research Institute, Durham, North Carolina; and Veterans Affairs Palo Alto Health Care System, Center for Primary Care and Outcomes Research, Stanford University, Stanford, California.


Acknowledgments: The authors thank Sara H. Cody, MD; David S. Stephens, MD; Christine H. Lee, MD; Ellen Jo Baron, PhD; Eva E. Shimaoka, MD; Justin Graham, MD; Michael K. Gould, MD, MS; Peter W. Groeneveld, MD, MS; and the CDC Public Service Response for their helpful input into the content and structure of the decision model.

Grant Support: By the University of Toronto and Sunnybrook and Women's College Health Sciences Centre (Dr. Fowler) and the Laughlin Fund (Dr. Garber).

Potential Financial Conflicts of Interest: Grants received: D.M. Bravata (Agency for Healthcare Research and Quality).

Requests for Single Reprints: Robert A. Fowler, MD, MS, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room D478, Toronto, Ontario M4N 3M5, Canada; e-mail, rob.fowler@sw.ca.

Current Author Addresses: Dr. Fowler: Departments of Medicine and Critical Care Medicine, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Room D478, Toronto, Ontario, M4N 3M5 Canada.

Dr. Sanders: Duke University, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715.

Drs. Bravata and Nouri: Center for Primary Care and Outcomes Research, 117 Encina Commons, Stanford University, Stanford, CA 94305-6019.

Mr. Gastwirth, Mr. Peterson, and Ms. Broker: Graduate School of Business, Stanford University, 518 Memorial Way, Stanford, CA 94305-5015.

Drs. Garber and Owens: Department of Veterans Affairs Palo Alto Health Care System and Center for Primary Care and Outcomes Research, 117 Encina Commons, Stanford University, Stanford, CA 94305-6019.

Author Contributions: Conception and design: R.A. Fowler, G.D. Sanders, D.M. Bravata, B. Nouri, J.M Gastwirth, D. Peterson, A.G. Broker, A.M. Garber, D.K. Owens.

Analysis and interpretation of the data: R.A. Fowler, G.D. Sanders, D.M. Bravata, B. Nouri, J.M Gastwirth, D. Peterson, A.G. Broker, A.M. Garber, D.K. Owens.

Drafting of the article: R.A. Fowler, G.D. Sanders, D.M. Bravata, J.M Gastwirth, B. Nouri, D. Peterson, A.G. Broker, A.M. Garber, D.K. Owens.

Critical revision of the article for important intellectual content: R.A. Fowler, G.D. Sanders, D.M. Bravata, A.M. Garber, D.K. Owens.

Final approval of the article: R.A. Fowler, D.M. Bravata, A.M. Garber, D.K. Owens.

Statistical expertise: R.A. Fowler, G.D. Sanders, D.M. Bravata, A.M. Garber, D.K. Owens.

Administrative, technical, or logistic support: R.A. Fowler.

Collection and assembly of data: R.A. Fowler, J.M Gastwirth, D. Peterson, B. Nouri, A.G. Broker, G.D. Sanders, D.M. Bravata, D.K. Owens.


Ann Intern Med. 2005;142(8):601-610. doi:10.7326/0003-4819-142-8-200504190-00008
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In this analysis, we assessed the costs and benefits of postattack and preattack strategies for an anthrax release of a greater magnitude than that previously experienced in the United States. The main finding of our analyses of postattack strategies is that use of vaccine plus antibiotic prophylaxis is the most effective and least expensive therapy. The savings associated with preventing cases of inhalational anthrax offset the cost of using both vaccination and antibiotics. This finding is robust even with reasonable changes in our estimates of the cost and efficacy of the vaccine and antibiotics. Our most important finding about preattack vaccination is that the net health benefit and cost-effectiveness depended critically on the probability of an attack and on the proportion of the population exposed during the attack. For a large metropolitan U.S. city, vaccination provides reasonable value for the health care dollar only when the probability of clinically significant exposure reaches about 1 in 200 (for example, when the probability of attack is 0.01 and the probability of exposure during an attack is 0.5, the joint probability of clinically significant exposures would be 0.005 or 1 in 200). Our findings highlight the inherent difficulties in decision making about anthrax vaccination. Several factors influence the probability that an individual will receive a clinically significant exposure during an attack, including the quantity of spores released, method of dissemination, and environmental factors (such as geography, wind conditions, and time of day of the dispersal) (46, 23, 65). Although it is difficult to judge the likelihood of a release and the probability of exposure given a release, clearly some individuals are at higher risk than others. Our finding that vaccination provides a net health benefit at even relatively low probabilities (1 in 500) may help decision-makers assess the desirability of vaccination of military and emergency services personnel, who are probably at greater risk for exposure than the general population. If a vaccine with fewer adverse reactions became available, the probabilities of exposure at which there may be net benefit would be lower.

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Figures

Grahic Jump Location
Figure 1.
Decision model for prophylactic vaccination and antibiotic strategies before and after a hypothetical anthrax bioterror attack.

Circles represent chance nodes, and squares represent decision nodes. Patients who have no exposure to Bacillus anthracis or who survive acute infection enter a process (represented by the diamond) that models pathway-specific annual probabilities of death and health, costs, and utilities for those who are healthy or disabled.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Cost-effectiveness of prophylactic vaccination and antibiotic strategies after a Bacillus anthracis bioterror attack.

QALY = quality-adjusted life-year.

Grahic Jump Location
Grahic Jump Location
Figure 3.
Sensitivity analysis of combined probabilities of attack and exposure on the incremental cost-effectiveness ratio of prophylactic vaccination before a Bacillus anthracis bioterror attack.

QALY = quality-adjusted life-year.

Grahic Jump Location
Grahic Jump Location
Figure 4.
Cost-effectiveness acceptability curve of vaccination and antibiotic prophylaxis after a Bacillus anthracisbioterror attack.

QALY = quality-adjusted life-year.

Grahic Jump Location

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Terrorism requires rapid answers.
Posted on April 26, 2005
Dr. Rajesh Chauhan
309/9 AV Colony, Sikandra, AGRA-282007. INDIA
Conflict of Interest: None Declared

Dear Editor,

We congratulate Robert A. Fowler and his team for their excellent in- depth study of the possible scenarios of anthrax abuse by terrorists and its cost effective management [1]. Terrorism can affect or cause to affect terror anywhere, by any means and by using any method, not necessarily the ¡¥anthrax¡¦. Therefore urgent need for similar studies on other biological and chemical agents exists. More importantly, the means of their easy, rapid and unambiguous detection is absolute must so as to be able to prevent rumors, panic and confusion. Modalities to make such gadgets readily available should be another area of study. The methods of containment and necessary preventive aspects should be spelt out clearly. Last but not the least, we keep our fingers crossed and pray that such terror incidents should never happen anywhere.

Regards.

"žX Dr. Rajesh Chauhan.

MBBS (AFMC), DFM, FCGP, ADHA, FISCD

Consultant Family Medicine & Communicable Diseases.

"žX Dr. Akhilesh Kumar Singh. MBBS, MD

Senior Resident Neurology

"žX Dr. Parul Kushwah. MBBS, MISCD

Family Medicine Practitioner.

Reference:

1. Fowler RA, Sanders GD, Bravata DM, Nouri B, Gastwirth JM, Peterson D, et al. Cost-Effectiveness of Defending against Bioterrorism: A Comparison of Vaccination and Antibiotic Prophylaxis against Anthrax. Ann Intern Med 2005; 142 (8): 601-10.

Conflict of Interest:

None declared

Submit a Comment

Summary for Patients

What Is the Most Cost-Effective Way To Protect People in the Event of an Anthrax Terror Attack?

The summary below is from the full report titled “Cost-Effectiveness of Defending against Bioterrorism: A Comparison of Vaccination and Antibiotic Prophylaxis against Anthrax.” It is in the 19 April 2005 issue of Annals of Internal Medicine (volume 142, pages 601-610). The authors are R.A. Fowler, G.D. Sanders, D.M. Bravata, B. Nouri, J.M. Gastwirth, D. Peterson, A.G. Broker, A.M. Garber, and D.K. Owens.

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