Clinical predictors of SARS-CoV-2 neutralizing antibody titers in COVID-19 convalescents: Implications for convalescent plasma donor recruitment

While COVID-19 convalescent plasma (CCP) efficacy is still under investigation in randomized controlled trials (RCT), CCP collections continue worldwide with largely variable criteria. Since it is well known that only a minority of patients develop high-titer neutralizing antibodies (nAb), as assessed by the viral neutralization tests (VNT), strategies to maximize cost-effectiveness of CCP collection are urgently needed. A growing amount of the population is having exposure to the virus and is hence becoming a candidate CCP donor. Laboratory screening with high-throughput serology has good correlations with the VNT titer, but upstream screening using clinical surrogates would be advisable. We review here the existing literature on clinical predictors of high-titer nAb. Older age, male sex, and hospitalization are the main proxies of high VNT and should drive CCP donor recruitment.

Blood and plasma donors during the COVID-19 pandemic: arguments against financial stimulation

During the COVID-19 pandemic, blood and convalescent plasma donors are dearly needed. There is a need to modify donor recruitment strategies in order to stimulate these donors. Financial stimulants though, cannot be possibly used. This paper will analyze, from an ethical perspective, the possible consequences regarding the blood and plasma donor system by a simple shift of attention from the voluntary unpaid donor to the paid one or the blood seller.

Effectiveness of hepatitis A vaccination as post-exposure prophylaxis

Hepatitis A (HA) has been a vaccine-preventable disease since 1995. In Catalonia, a universal combined hepatitis A+B vaccination program of preadolescents was initiated at the end of 1998. However, outbreaks are reported each year and post-exposure prophylaxis (PEP) with hepatitis A virus (HAV) vaccine or immunoglobulin (IG) is recommended to avoid cases. The aim of this study was to assess the effectiveness of HAV vaccine and IG in preventing hepatitis A cases in susceptible exposed people. A retrospective cohort study of contacts of HA cases involved in outbreaks reported in Catalonia between January 2006 and December 2012 was made. The rate ratios and 95% confidence intervals (CI) of HA in susceptible contacts receiving HAV or IG versus those without PEP were calculated. There were 3550 exposed persons in the outbreaks studied: 2381 received one dose of HAV vaccine (Hepatitis A or hepatitis A+B), 190 received IG, and 611 received no PEP. 368 exposed subjects received one dose of HAV vaccine and IG simultaneously and were excluded from the study. The effectiveness of PEP was 97.6% (95% CI 96.2-98.6) for HAV vaccine and 98.3% (95% CI 91.3-99.9) for IG; the differences were not statistically significant (p = 0.36). The elevated effectiveness of HAV vaccination for PEP in HA outbreaks, similar to that of IG, and the long-term protection of active immunization, supports the preferential use of vaccination to avoid secondary cases.

Cost-effectiveness of testing hepatitis B-positive pregnant women for hepatitis B e antigen or viral load

OBJECTIVE

To estimate the cost-effectiveness of testing pregnant women with hepatitis B (hepatitis B surface antigen [HBsAg]-positive) for hepatitis B e antigen (HBeAg) or hepatitis B virus (HBV) DNA, and administering maternal antiviral prophylaxis if indicated, to decrease breakthrough perinatal HBV transmission from the U.S. health care perspective.

METHODS

A Markov decision model was constructed for a 2010 birth cohort of 4 million neonates to estimate the cost-effectiveness of two strategies: testing HBsAg-positive pregnant women for 1) HBeAg or 2) HBV load. Maternal antiviral prophylaxis is given from 28 weeks of gestation through 4 weeks postpartum when HBeAg is positive or HBV load is high (10 copies/mL or greater). These strategies were compared with the current recommendation. All neonates born to HBsAg-positive women received recommended active-passive immunoprophylaxis. Effects were measured in quality-adjusted life-years (QALYs) and all costs were in 2010 U.S. dollars.

RESULTS

The HBeAg testing strategy saved $3.3 million and 3,080 QALYs and prevented 486 chronic HBV infections compared with the current recommendation. The HBV load testing strategy cost $3 million more than current recommendation, saved 2,080 QALYs, and prevented 324 chronic infections with an incremental cost-effectiveness ratio of $1,583 per QALY saved compared with the current recommendations. The results remained robust over a wide range of assumptions.

CONCLUSION

Testing HBsAg-positive pregnant women for HBeAg or HBV load followed by maternal antiviral prophylaxis if HBeAg-positive or high viral load to reduce perinatal hepatitis B transmission in the United States is cost-effective.

[Role of antivenoms in the treatment of snake envenomation]

The production of antivenoms, which were long deemed ineffective, dangerous and difficult to use, has improved dramatically. These antibodies (immunoglobulin G) are now fragmented, purified and controlled for their quality, leading to significantly better safety and facilitating their emergency use. Envenomation can result in various syndromes depending on the snake species: Viperidae venoms are highly inflammatory, hemorrhagic and necrotising, while Elapidae venoms can cause fatal respiratory paralysis. However, some Viperidae venoms can lead to asphyxiation similar to that observed in Elapidae envenomation while, conversely, Elapidae bites may be complicated by hemorrhage or necrosis, thus complicating etiologic diagnosis. Symptomatic treatment is complex, often insufficient, and frequently associated with adverse events. In contrast, antivenoms neutralize the venom and accelerate its clearance, thus providing an etiological treatment for envenomation, particularly in remote healthcare facilities in developing countries. Current formulations consist of polyvalent antivenoms covering most of the venomous species present in a specific region. The main limitation is their high cost, and the priority should be to develop new treatment strategies, including more affordable antivenoms, especially in developing countries where they are most needed.

Management of primary antibody deficiency with replacement therapy: summary of guidelines

This article summarizes the guidelines for using replacement therapy in the management of patients who have primary antibody deficiency.

Subcutaneous immunoglobulin replacement therapy for primary antibody deficiency: advancements into the 21st century

OBJECTIVES

To provide a review of the world literature and discuss the clinical role of subcutaneous immunoglobulin (SCIG) therapy for primary antibody deficiency.

DATA SOURCES

English-language publications on SCIG therapy were identified through MEDLINE and through the reference list of the initially identified publications.

STUDY SELECTION

Articles pertaining to SCIG for the treatment of immunodeficiency, particularly primary antibody deficiency, were selected.

RESULTS

SCIG therapy has been shown to be effective and safe for the treatment of primary immunodeficiency. The risk of systemic reactions during infusion is generally reported to be less than 1%. Many patients prefer SCIG over conventional intravenous immunoglobulin therapy because of increased convenience and independence associated with SCIG therapy. Publications show SCIG therapy to be advantageous in selected patient populations, such as children, pregnant women, and patients with poor intravenous access.

CONCLUSION

SCIG therapy has been widely used in some European countries for a number of years, but a Food and Drug Administration-approved product was only recently introduced into the United States in 2006. SCIG therapy offers unique advantages that are applicable to many patients receiving immunoglobulin therapy for primary immunodeficiency.

Passive transfer of immunoglobulin G and preweaning health in Holstein calves fed a commercial colostrum replacer

The objective of this study was to describe passive transfer of IgG and preweaning health in newborn calves fed a commercially available plasma-derived colostrum replacement (CR) product or maternal colostrum (MC). Twelve commercial Holstein dairy farms enrolled singleton newborn heifer calves to be fed fresh MC (n = 239 calves) or one dose of CR containing 125 g of Ig (n = 218 calves) as the first colostrum feeding. For 7 of these farms that routinely provided a second feeding of 1.9 L of MC to their calves 8 to 12 h after the first colostrum feeding, calves assigned to the CR treatment group were offered a second feeding consisting of 1.9 L of commercial milk replacer supplemented with one dose of a commercially available plasma-derived colostrum supplement, containing 45 g of Ig per dose, 8 to 12 h after the first colostrum feeding. A blood sample was collected from all calves between 1 to 8 d of age for serum IgG and total protein (TP) determination, and records of all treatment and mortality events were collected until weaning. Serum IgG and TP concentrations were significantly higher in calves fed MC (IgG = 14.8 +/- 7.0 mg/mL; TP = 5.5 +/- 0.7 g/dL) compared with calves fed CR (IgG = 5.8 +/- 3.2 mg/mL; TP = 4.6 +/- 0.5 g/dL). The proportion of calves with failure of passive transfer (serum IgG <10.0 mg/mL) was 28.0 and 93.1% in the MC and CR treatment groups, respectively. Though a trend was present, the proportion of calves treated for illness was not statistically different for calves fed MC (51.9%) vs. CR (59.6%). Total number of days treated per calf (MC = 1.7; CR = 2.0), treatment costs per calf (MC = $10.84; CR = $11.88), and proportion of calves dying (MC = 10.0%; CR = 12.4%) was not different between the 2 colostrum treatment groups. The mean serum total protein concentration predictive of successful passive transfer (serum IgG = 10 mg/mL) was 5.0 g/dL in calves fed MC or CR. Long-term follow-up of these calves (to maturity) is ongoing to describe the effects of feeding CR on longevity, productivity, risk for Johne's disease, and economics.

[Current approaches to emergency specific prevention of tick-borne encephalitis]

Emergency specific prevention of tick-borne encephalitis (TBE) by using homologous immunoglobulin is an important element in the package of controlling measures against this viral natural and focal infection. There are annually a few hundred thousand referrals for health care facilities for tick bites. Their maximum coverage tactics via immunoglobulin prevention is medically unreal and unjustifiable. The paper presents the results of a long-term application of another approach based on preliminary rapid studies of the ticks taken from victims or the blood of patients in the period of possible development of virusemia and preventive immunoglobulin use only in the persons bitten with TBE virus-infected ticks. Examination of the material available from more than 56 thousand referrals indicated the high epidemiological (more than 99%) and economic effectiveness of the target administration of an immunological drug. By taking into account the accumulated data on a wide spread of combined foci of TBE and other tick-borne infections and the authors' own experience, it is suggested that it is necessary to organize a comprehensive differential laboratory diagnosis and emergency prevention against the whole complex of Ixodes tick-borne infections.

VZV infection in pregnancy: a retrospective review over 5 years in Sheffield and discussion on the potential utilisation of varicella vaccine in prevention

OBJECTIVES

To study retrospectively the epidemiology, demography and clinical issues related to varicella in pregnancy in a UK city over a 5-year period and help inform the debate on the potential of varicella immunisation in prevention.

METHODS

The hospital records of pregnant women with varicella receiving care at the Regional Department of Infection and Tropical Medicine in Sheffield between 1997 and 2002 were reviewed. Data on pregnant women with varicella not presenting acutely to medical care were obtained. The use of Varicella Zoster Immune Globulin (VZIG) in prevention of varicella during the same 5-year period was determined. The records from the maternity department of Sheffield Hospitals for women undergoing VZV antibody testing between January and December 2004 were reviewed. Data on annual number of deliveries were recorded and the neonatology database used as a source of information regarding effects of chickenpox on the baby.

RESULTS

The incidence of varicella infection in pregnancy was at least 6 per 10,000 deliveries. Nineteen pregnant women with varicella were admitted to hospital. Three had pneumonia. Infection occurred in the first pregnancy in a quarter of cases. The minimum cost for all cases admitted to hospital during this period (basic costs per day) was 20,520 pounds sterling. The cost of VZIG use for chickenpox during the same period adjusted for the population size was 10,881 pounds sterling. This was not a comprehensive health economic study and did not attempt to assess additional GP, midwifery, obstetric or social costs nor costs associated with those who did not attend hospital. Two hundred and thirty-three women underwent VZV antibody test during 2004 usually after contact with chickenpox. Sixty percent of women in contact with chickenpox did not present to their GP or hospital immediately.

CONCLUSION

Varicella in pregnancy may be associated with significant morbidity and health care cost and prevention by immunisation is desirable. Though targeted vaccination is attractive, screening in pregnancy followed by a post-partum varicella immunisation programme would fail to protect 25% and would be associated with logistical challenges not occurring with rubella immunisation. Varicella is now a preventable disease by immunisation. Exposure in pregnancy with or without infection has financial costs related to antibody testing and prophylaxis. Infection in pregnancy may be associated with additional costs and potential morbidity to mother and baby. Potential immunisation strategies are considered.

Comparison of cost of immune globulin intravenous therapy to conventional immunosuppressive therapy in treating patients with autoimmune mucocutaneous blistering diseases

Autoimmune mucocutaneous blistering diseases (AMBD) are a group of potentially fatal diseases that affect the skin and mucous membranes. AMBD have different target antigens as well as variable clinical presentation, course, and prognosis. The mainstay of conventional immunosuppressive therapy (CIST) for AMBD is long-term high-dose systemic corticosteroids and immunosuppressive agents. Such therapy has proven effective in many patients; however, in some patients, the disease continues to progress with significant sequelae such as blindness, loss of voice, anal, and vaginal stenosis which causes poor quality of life. Furthermore, the CIST may have some serious side effects including opportunistic infections which may cause death. Immune globulin intravenous (IGIV) therapy has been reportedly used in the management of patients with AMBD refractory to CIST. IGIV has shown to be more clinically beneficial than CIST by bringing about long-term clinical remission and less recurrence. The high cost of the IGIV is of concern to patients, physicians, and insurance companies. In this report, we compare the cost of IGIV to that of CIST in treating a cohort of 15 mucous membrane pemphigoid (MMP), 10 ocular cicatricial pemphigoid (OCP), 15 bullous pemphigoid (BP), and 32 pemphigus vulgaris (PV) patients. In each cohort of patients, CIST had significant side effects, many of which were hazardous and required prolonged and frequent hospitalizations. Some of these side effects were severe enough to require discontinuation of the treatment. We consider the total cost of CIST to be the actual cost of the drug, plus the cost of management of the side effects produced by CIST. In the same patient cohort, no significant side effects to IGIV were observed. None of the IGIV treated patients required physician visits, laboratory tests, or hospitalizations specifically related to IGIV therapy. Hence, the total cost of the IGIV therapy is the actual cost of the IGIV only. The mean total cost of treatment of IGIV therapy is statistically significantly less than that of CIST during the entire course of the disease and on an annual basis. In conclusion, IGIV therapy is a safe, clinically beneficial, and a cost effective alternative treatment in patients with AMBD, non-responsive to CIST.

Comparison of intravenous ganciclovir and cytomegalovirus hyperimmune globulin pre-emptive treatment in cytomegalovirus-positive heart transplant recipients

BACKGROUND

We compared the use of intravenous ganciclovir and cytomegalovirus hyperimmune globulin (CMVIG) as a pre-emptive treatment for cytomegalovirus (CMV)-positive heart transplant recipients.

METHODS

Of 59 CMV-seropositive adult heart transplant recipients enrolled in Group 1, 37 tested positive for pp65 antigen within 12 weeks post-transplantation. These patients were randomized to receive either intravenous ganciclovir (n = 23) or CMVIG (n = 14). Group 2 included 133 CMV-seropositive heart transplant recipients who were not tested for CMV antigenemia and who received no anti-CMV therapy.

RESULTS

CMV disease developed in 0 of 59 patients from Group 1, and in 27 of 133 patients (20%) in Group 2 (p = 0.0001). The incidence of superinfections was lower in Group 1 (0.28 +/- 0.46) than in Group 2 (1.10 +/- 1.33) (p = 0.01). The 2 groups did not differ with regard to incidence of rejection (0.7 +/- 0.9 in Group 1 vs 1.0 +/- 1.2 in Group 2; p = NS), transplant coronary artery disease at 1 year (14% in Group 1 vs 16% in Group 2; p = NS) or post-transplant lymphoproliferative disease (0% in Group 1 vs 2% in Group 2; p = NS). Ganciclovir and CMVIG therapies were associated with similar rates of rejection (0.52 +/- 0.6 with ganciclovir vs 0.50 +/- 0.60 with CMVIG; p = NS), superinfection (0.30 +/- 0.48 with ganciclovir vs 0.25 +/- 0.46 with CMVIG; p = NS), and transplant coronary artery disease at 1 year (13% with ganciclovir vs 14% with CMVIG, p = NS).

CONCLUSIONS

The pre-emptive anti-CMV approach is superior to prophylaxis in CMV-seropositive heart transplant recipients. Both ganciclovir and CMVIG are equally effective.

Effectiveness of drug therapies to treat or prevent respiratory syncytial virus infection-related morbidity

Respiratory syncytial virus (RSV) infection causes a huge burden to the health service, as it results in a large number of in-patient days each year and increases the risk of asthma in childhood. In the acute phase, therapy is supportive as bronchodilators and corticosteroids have resulted, at best, only in short-term benefits; promising treatments for ventilated patients, such as exogenous surfactant, require further testing. Passive immunoprophylaxis reduces hospital admission in high risk groups. In the prevention of chronic respiratory morbidity following RSV infection, however, studies are needed to determine whether immunoprophylaxis will have a useful role and to identify which drug treatment will be most cost-effective.

Cost-utility analysis of intravenous immunoglobulin and prednisolone for chronic inflammatory demyelinating polyradiculoneuropathy

The aim of this study was to provide an incremental cost-effectiveness analysis comparing intravenous immunoglobulin (IVIg) and prednisolone treatment for chronic inflammatory demyelinating polyradiculoneuropathy. Patients were recruited to a double-blind randomized crossover trial from nine European centres and received either prednisolone or IVIg during the first 6-week treatment period on which the economic evaluation was based. A societal perspective was adopted in measuring service use and costs, although the costs of lost employment were not included. The main outcome measure in the economic evaluation was the number of quality adjusted life years (QALYs) gained, with change in a 11-point disability scale used to measure clinical outcomes. Service use and quality of life data were available for 25 patients. Baseline costs were controlled for using a bootstrapped multiple regression model. The cost difference between the two treatments was estimated to be euro 3754 over the 6-week period. Health-related quality of life, as measured by the EuroQol EQ-5D instrument, increased more in the IVIg group but the difference was not statistically significant. Using a net-benefit approach it was shown that the probability of IVIg being cost-effective in comparison with prednisolone was 0.5 or above (i.e. was more likely to be cost-effective than cost-ineffective) only if one QALY was valued at over euro 250 000. The cost-effectiveness of IVIg is greatly affected by the price of IVIg and the amount administered. The impact of later side-effects of prednisolone on long-term costs and quality of life are likely to reduce the cost per QALY of IVIg treatment.

Cost-effective and safe ambulatory long-term immunoprophylaxis with intramuscular instead of intravenous hepatitis B immunoglobulin to prevent reinfection after orthotopic liver transplantation

BACKGROUND

Hepatitis B (HBV)-infected patients receive an anti-HBs immunoprophylaxis [hepatitis B immunoglobulin (HBIG) titre of more than 100 IU/L] in combination with lamivudine to prevent reinfection after orthotopic liver transplantation (OLT). In comparison with intramuscular (i.m.) HBIG, costs for intravenous (i.v.) HBIG are found to be extremely high. We therefore studied patients' outcome (i) after a switch from i.v. to i.m. HBIG and (ii) the outcome after the patients were initially treated with i.m. HBIG after discharge from the hospital.

METHODS

(i) Six outpatients were switched from 2000 IU i.v. HBIG (Hepatect) administered every 2 wk to 2000 IU i.m. HBIG (Hepatitis-B-Immunoglobulin Behring) given once a month. (ii) Six other outpatients were directly treated with i.m. HBIG every 4 wk after OLT. All patients also received 100 mg lamivudine/d.

RESULTS

Patients switched from i.v. to i.m. HBIG had stable anti-HBs titres (i.v. HBIG: 180 +/- 37 IU/L vs. i.m. HBIG: 173 +/- 23 IU/L). Patients directly treated with i.m. HBIG also had sufficient anti-HBs titres (176 +/- 31 IU/L). Intramuscular application of HBIG was well tolerated by all patients and no side-effects were observed in patients receiving i.m. HBIG. In comparison with the protocol using i.v. HBIG, the costs of i.m. treatment were 60% lower.

CONCLUSION

Long-term administration of i.m. HBIG saves up to 60% of the usual costs for i.v. prophylaxis of HBV reinfection in patients after OLT. In combination with lamivudine, long-term i.m. HBIG therapy is as efficient as i.v. HBIG treatment, but its lower costs clearly favour its use in preventing HBV reinfection after OLT.

Cost of hospitalization for respiratory syncytial virus chest infection and implications for passive immunization strategies in a developing nation

Respiratory syncytial virus (RSV) chest infection is a common cause of hospitalization in the very young child. The aim of this study was to determine the direct cost of resource utilization in the treatment of children hospitalized with RSV chest infection and the potential cost-savings with passive immunization for high-risk infants. An audit of the hospital resource consumption and its costs was performed for 216 children aged < 24 mo admitted with RSV chest infection between 1995 and 1997. The cost-saving potential of passive immunization using monoclonal RSV antibodies during the RSV season was determined by assuming an 0.55 efficacy in hospitalization reduction when administered to "high-risk" infants according to the guidelines outlined by the American Academy of Pediatrics (AAP). The hospital treatment cost of 1064 bed-days amounted to USD 64 277.70. Each child occupied a median of 4.0 bed-days at a median cost of USD 169.99 (IQ1 128.08, IQ3 248.47). Children, who were ex-premature or with an underlying illness were more likely to have a longer hospital stay, higher treatment costs and need for intensive care. Ten (42%) of 24 ex-premature infants fulfilled the recommended criteria for passive immunization. Its use resulted in an incremental cost of USD 31.39 to a potential cost saving of USD 0.91 per infant for each hospital day saved.

CONCLUSION

Ex-prematurity and the presence of an underlying illness results in escalation of the direct treatment cost of RSV chest infection. Current guidelines for use of passive RSV immunization do not appear to be cost-effective if adopted for Malaysian infants.

Cost-reducing protein production and delivery for sexually transmitted disease prevention

Table 2 summarizes our two approaches: vaginal delivery of antibodies to immunize passively and edible microspheres for active immunization. These approaches have different roles in disease prevention in communities and each may be most useful for different kinds of diseases. The passive approach could easily be extended to lots of different sexually transmitted diseases by just changing the specificity of the antibody incorporated into the device. The active immunization approach requires more specific development steps for each particular type of disease. Detailed analysis of the cost-reduction potential of these approaches is not yet available, but estimates of the cost to manufacture these products can be made, based on the initial laboratory studies (Table 4). The results to date suggest that both products are feasible and that they could be manufactured as cheaply as other products (such as condoms and oral contraceptives) that people currently use for sexual health. All products, once made available, could have a significant impact on the reduction of healthcare costs.

Economic analyses of respiratory syncytial virus immunoprophylaxis in high-risk infants: a systematic review

OBJECTIVE

To systematically review all published economic analyses of the only 2 available agents for respiratory syncytial virus immunoprophylaxis in high-risk infants: respiratory syncytial virus immunoglobulin intravenous and palivizumab.

DATA SOURCES

Economic evaluations of respiratory syncytial virus immunoprophylactic agents were identified from the MEDLINE and HealthSTAR databases using various combinations of the following search terms: respiratory syncytial virus immunoglobulin intravenous, palivizumab, cost, and cost-effectiveness. The search was limited to articles published in English between January 1, 1990, and August 31, 2001. Additional studies were obtained by searching bibliographies of all relevant identified articles.

STUDY SELECTION

Only studies that performed an economic analysis of either or both of these agents in an infant population were included. Letters to the editor and commentaries that included informal economic analyses were excluded. Twelve of the 21 identified studies met the selection criteria.

DATA EXTRACTION

Two of us (S.K.-B. and J.D.) independently reviewed the articles and extracted summary information using a standardized abstraction form, with differences resolved by consensus.

DATA SYNTHESIS

Estimates ranging from cost savings to considerable incremental costs per hospitalization avoided with use of either agent were observed across studies. Studies comparing the 2 agents reported mixed results about their relative cost-effectiveness in different infant subgroups. The divergent results may be explained by differences in the study methods and assumptions, but they also reflect the poor quality of some of the economic analyses.

CONCLUSION

In light of the issues identified in this review, providers, payers, and health policymakers need to critically appraise and judiciously interpret cost-effectiveness research on these agents.

Pharmacoeconomic analysis of HBV liver transplant therapies

The outcome of liver transplantation for patients infected with the hepatitis B virus (HBV) has greatly improved over the last several years. The rate of allograft infection has decreased from 85 to 25%, while the post-transplant mortality rate due to HBV has decreased from 50% at 18 months to nearly nonexistent. For the most part, this result has been due to the increased dose and extended use of hepatitis B immunoglobulin (HBIg). Current lack of knowledge of the amount of HBIg monotherapy that is necessary to suppress residual virus has led to an expensive therapy. In our early experience, no alternative existed at the time of transplant for this group of recipients. Administration of HBIg was directed toward patient safety and optimal outcome rather than cost containment. The significance of the economic impact of this decision is discussed in this article. Analysis of institutional expenses revealed that the cost of HBIg to establish viral control was fairly consistent over time, despite the increased purchase price of the drug. Individualized dosing of HBIg was more expensive in the first year after transplantation compared to typical monthly administration protocols, but was substantially less expensive after 12 months due to decreased dosage needs. In addition to HBIg acquisition price, factors that affect expenditure for HBIg maintenance include time intervals between doses, purchase contracts, overhead of drug administration, and methods employed in determining charge structures. Combination therapies with nucleoside analogues may have a beneficial effect on future costs. Controlled trials to identify the optimum and most cost-effective therapy need to be performed.

An efficacy and cost-effectiveness analysis of combination hepatitis B immune globulin and lamivudine to prevent recurrent hepatitis B after orthotopic liver transplantation compared with hepatitis B immune globulin monotherapy

Orthotopic liver transplantation (OLT) for hepatitis B virus (HBV) infection was limited until recently by poor graft and patient outcomes caused by recurrent HBV. Long-term immunoprophylaxis with hepatitis B immune globulin (HBIG) dramatically improved post-OLT survival, but recurrent HBV still occurred in up to 36% of the recipients. More recently, combination HBIG and lamivudine has been shown to effectively prevent HBV recurrence in patients post-OLT. The aim of the current study is to determine long-term outcome and cost-effectiveness of using combination HBIG and lamivudine compared with HBIG monotherapy in patients who undergo OLT for HBV. A retrospective chart review identified 59 patients administered combination HBIG and lamivudine and 12 patients administered HBIG monotherapy as primary prophylaxis against recurrent HBV. Lamivudine, 150 mg/d, was administered orally indefinitely. HBIG was administered under a standard protocol (10,000 IU intravenously during the anhepatic phase, then 10,000 IU/d intravenously for 7 days, then 10,000 IU intravenously monthly) indefinitely. A decision-analysis model was developed to evaluate the potential economic impact of prophylaxis against HBV with combination therapy compared with monotherapy. Recurrent HBV was defined as the reappearance of hepatitis B surface antigen (HBsAg) after its initial disappearance post-OLT. In the combination-therapy group, no patient redeveloped serum HBsAg or HBV DNA during mean follow-ups of 459 and 416 days, respectively. In the monotherapy group, 3 patients (25%) had reappearance of HBsAg in serum during a mean follow-up of 663 days. Combination therapy resulted in a dominant, cost-effective strategy with an average cost-effectiveness ratio of $252,111/recurrence prevented compared with $362,570/recurrence prevented in the monotherapy strategy. Combination prophylaxis with HBIG and lamivudine is highly effective in preventing recurrent HBV, may protect against the emergence of resistant mutants, and is significantly more cost-effective than HBIG monotherapy with its associated rate of recurrent HBV.

Respiratory syncytial virus prevention: past and present strategies

Respiratory syncytial virus (RSV) is a common cause of respiratory illness in young children, almost all will have been infected by the age of two years old. Very young infants, and those with underlying disease, are at risk of severe RSV disease, but even those who were previously healthy can suffer recurrent respiratory symptoms 9 to 10 years after their initial infection. The management of RSV infection is essentially supportive, thus prophylaxis offers the best hope of reducing the morbidity and mortality of RSV infection. There is no safe and effective RSV vaccine to use in those infants who are at highest risk from the infection. Immunoprophylaxis, however, has been shown to have benefits in randomised controlled trials. Standard immunoglobulin, however, is ineffective as its administration does not achieve an adequate titre of neutralising antibodies. RSV immunoglobulin (RSV-IGIV, RespiGam, Massachusetts Public Health Laboratories, Boston, MA), in contrast, contains high levels of RSV neutralising antibody and has been shown to significantly reduce hospitalisation in preterm infants with or without bronchopulmonary dysplasia (BPD). Its use is not recommended in infants with cyanotic congenital heart disease (CHD), as it was associated with an excess of adverse events. A humanised RSV monoclonal antibody (Palivizumab, MEDI-493, Synagis, MedImmune Inc, Gaithersburg, MD) also significantly reduces hospitalisation for RSV infection in high risk infants, but without serious side effects. The American Academy of Paediatrics has recommended that immunoprophylaxis should be considered for young children at high risk of severe RSV infection and that palivizumab is the preferred agent. Studies have suggested it is essential to carefully select patients for immunoprophylaxis, if its use is to be cost-effective.

Hospitalisation for RSV infection in ex-preterm infants-implications for use of RSV immune globulin

BACKGROUND

Respiratory syncytial virus (RSV) specific immune globulin is now being marketed for prevention of RSV infection in ex-preterm infants. However, there are no published UK data on the morbidity or mortality from RSV in these infants.

AIMS

To determine the morbidity and mortality from RSV infection in a cohort of infants previously treated at a regional neonatal unit, and compare the cost of hospitalisation for RSV with the potential cost of administering RSV immune globulin (RSV-IG) prophylaxis.

METHODS

Infants born at a gestation of less than 32 weeks were studied. Details of admissions for respiratory illness in the first two years of life were collected from hospital records, referring hospitals, and general practitioners.

RESULTS

Data on 82 infants were collected. Up to three RSV seasons were encountered. The hospitalisation rate for confirmed RSV infection for the first season encountered was 4%. Rates of ward and paediatric intensive care unit admission were higher for infants with chronic lung disease. There were no deaths from RSV. RSV-IG would not have been cost effective for most infants.

CONCLUSION

The morbidity and mortality rates from RSV observed in this group do not support the widespread introduction of RSV-IG prophylaxis for ex-preterm infants.

Cytomegalovirus immune globulin after liver transplantation: a cost-effectiveness analysis

OBJECTIVE

Cytomegalovirus (CMV) immune globulin (CMVIG) has been shown to significantly reduce severe CMV-associated disease complicating orthotopic liver transplant (OLT). We evaluated the economic impact of severe CMV-associated disease and calculated the marginal cost-effectiveness (C/E) of routine prophylaxis with CMVIG after OLT.

DESIGN

C/E analysis.

SETTING

Four teaching hospitals in Boston.

PATIENTS

Patients who underwent OLT from January 1988 through June 1990.

MEASUREMENTS

We gathered actual cost data of hospital care for patients enrolled in a clinical trial of CMVIG prophylaxis in OLT. We calculated average outpatient expenses from a separate group of patients undergoing OLT and developed a regression model to estimate costs during the first year post-transplant (R2 = 0.77). Based on this model, we calculated variable costs (in 1999 US dollars) for all patients in the randomized trial. From the published literature we obtained the probability of CMV outcomes and of long-term survival after OLT. We then developed a decision analytical model to determine an incremental C/E ratio, using a Markov simulation to estimate long-term survival and long-term costs. We discounted costs and life-years at 3% and 5% per yr.

RESULTS

Based on the efficacy rate of 54% in the controlled trial, we estimate that CMVIG will increase life expectancy by 0.65 discounted years at an additional cost of $11,600, providing a marginal C/E ratio of $17,900/yr life saved. Examining the confidence limits of efficacy, we estimate that CMVIG will have a marginal C/E ratio of $66,200 gained/yr at an efficacy of 11% and $14,000 gained/yr at an efficacy of 83%.

CONCLUSION

After OLT, prophylactic CMVIG has an incremental C/E ratio comparable to that of other well-accepted medical therapies and should be used routinely in these patients.

Cost-effective analysis of hepatitis A prevention in Ireland

OBJECTIVE

The purpose of this study was to determine the most cost-effective prevention strategy against hepatitis A virus (HAV) infection for healthcare workers and the general population at risk in Ireland.

METHODS

Four prevention strategies were compared: active immunization with Havrix Monodose (1440E.U); screening for anti-HAV antibody and then vaccinating; passive immunization; screening for anti-HAV antibody and then passive immunization. The cost-effective ratio was calculated for each prevention strategy. Threshold analysis, sensitivity analysis, and model extension to include indirect cost from work days lost and secondary attack rates through horizontal transmission were also derived.

RESULTS

The medical costs were lowest and the infection rate highest when no preventive action was taken. Vaccination was most cost effective when the prevalence of immunity was 45% or less, reducing the infection rate by 98% when compared to nonprevention. Screening before vaccination was most cost effective when the prevalence of immunity was greater than 45%. Passive immunization and screening before passive immunization were not comparable to the other strategies in cost effectiveness. Sensitivity analysis showed that the cost-effective ratio for vaccination was dependent on vaccine price, incidence of HAV, and prevalence of immunity in the target group. Extending the model to include indirect costs further increased the cost effectiveness of vaccination.

CONCLUSION

The best cost-effective strategy relates to target group immunity. Where HAV immunity is 45% or less, vaccination is the strategy of choice and when immunity is greater than 45%, then screening followed by vaccination should be used. This study can be used to provide a framework within which choices can be made to achieve better health for less cost.

Comparison of ganciclovir- and immune globulin-containing regimens in preventing cytomegalovirus infection in patients with renal transplants

The effectiveness and costs of ganciclovir compared with intravenous immune globulin (IVIG) in the prevention of cytomegalovirus (CMV) disease were studied. A retrospective analysis was conducted of renal transplant patients treated with ganciclovir during the initial hospital stay followed by three months of acyclovir therapy and a historical control group that received IVIG at one, two, four, six, and eight weeks posttransplant and acyclovir at two weeks posttransplant and continued for three months. The average drug cost for each regimen and the average direct cost of treating CMV disease in each group were calculated. The overall frequency of CMV disease was 14% in the IVIG group (n = 42) and 3% in the ganciclovir group (n = 30). CMV disease occurred less frequently in all ganciclovir-treated subgroups, but the difference was significant only in the group in which the recipient was CMV seronegative and the donor CMV seropositive. No ganciclovir-related adverse events were noted. Three IVIG-related infusion reactions were noted. Treatment with ganciclovir decreased drug costs by approximately $2,775 per patient or $83,250 for the study sample. The overall avoided cost in the ganciclovir group was $102,575 ($3,419 per patient). Ganciclovir followed by acyclovir was significantly more effective than IVIG followed by acyclovir in the prevention of CMV disease in CMV-seronegative patients who received renal transplants from CMV-seropositive donors; among all patients studied, ganciclovir did not differ from IVIG in preventing CMV infection but was considerably less expensive.

[Treatment with immunoglobulins]

The application of various formulations of immunoglobulins has become feasible for an impressive array of indications, and the number of available preparations is quite considerable. Nevertheless aside from immunologic/haematologic routine the relation of promise, cost and risk is hard to estimate. This presentation will try to review these factors for certain groups of diseases.

Causes, costs, and estimates of rabies postexposure prophylaxis treatments in the United States

The incidence of rabies in humans in the United States is low. However, contacts with potentially rabid animals result in thousands of human rabies postexposure prophylaxis treatments (PEPs) each year. PEP is expensive, not without risk of adverse reactions, and in many instances unnecessary. Increased reports of cases of rabies in animals (4,880 cases in 1990, 9,495 in 1993, and 7,124 in 1996) suggested that PEPs could be increasing. Application of 1981 PEP incidence rates gave an estimate of approximately 16,000 PEPs during 1996, while calculations based on annual sales of a rabies biological during 1996 gave an estimate of approximately 39,000 PEPs. Appropriate usage of PEP requires careful evaluation of human exposure scenarios and adherence to approved guidelines.

A number-needed-to-treat analysis of the use of respiratory syncytial virus immune globulin to prevent hospitalization

OBJECTIVES

To estimate how many infants in selected high-risk subgroups would require treatment with respiratory syncytial virus immune globulin (RSV-IG) to avoid 1 hospital admission and to determine whether this is economically justified.

DESIGN

Cost-benefit analysis. Data from 3 randomized controlled trials of RSV-IG are used to estimate the number needed to treat to prevent 1 hospital admission for respiratory syncytial virus infection. The threshold number needed to treat is computed according to a formula incorporating costs and benefits of RSV-IG prophylaxis. Estimates of the willingness to pay were obtained from a sample of 39 health care providers (35 physicians and 4 nurses).

MAIN OUTCOME MEASURES

The number needed to treat to prevent 1 hospital admission for respiratory syncytial virus infection. The threshold number needed to treat that would balance costs with benefits.

RESULTS

More than 16 (95% confidence interval, 12.5-23.8) infants would need to be treated with RSV-IG to avoid 1 hospital admission for respiratory syncytial virus infection, ranging from 63 for premature infants without chronic lung disease to 12 (confidence interval, 6.3-100.0) for infants with bronchopulmonary dysplasia. A sensitivity analysis of the costs and values of hospital admission for respiratory syncytial virus infection and RSV-IG treatment resulted in a weak recommendation against the treatment of infants with bronchopulmonary dysplasia and strong recommendations that the costs and risks of RSV-IG treatment outweigh the benefits for the combined sample of infants and premature infants without lung disease.

CONCLUSIONS

The number-needed-to-treat procedures offer a method to assess evidence of treatment effects and decision rules for whether to accept treatment recommendations. Under plausible assumptions, treatment with RSV-IG is not recommended for infants without lung disease. Institutions can examine cost and benefit assumptions that best fit their own practice setting.

[Traceability of drugs derived from blood: regulation and pharmaco-economic implications after 24 months of application in Paris CHU]

Since January 1, 1995, the supply, stockage, dispensing and traceability of Blood Derivative Medicinal Products (BDMP) are subject to pharmaceutical regulations. A review of 24 months' application at Necker-Enfants Malades Hospital is presented and analysed. A distinction is drawn between two categories of BDMP: 1) anti-hemophilia BDMP, factors of plasma or recombinant origin; 2) non-anti-hemophilia BDMP, covering albumin, immunoglobulins (Ig), biological glues and other clotting factors. BDMP are subject to a hospital traceability procedure. In this respect, we have constructed a tryptic nominative model prescription, though dotations are granted for only certain prescription sectors (operating room, ICU) and certain products (biological glues, albumins). A dispensing-administration form is invariably attached to each bottle. Between January 1, 1995 and December 31, 1996, 8225 dispensing procedures for BDMP were recorded, with a total cost of 52,931,586 francs (i.e. 69% anti-hemophilia products v.s. 31% non-antihemophilia products). The Factor VIII market is divided more or less equally between factors of human and recombinant origin. The risk of viral transmission is considered to be virtually nil with recombinant products, despite their being stabilized by human albumin. The traceability rate of anti-hemophilia factors was 100%. Albumin consumption was 182,106 g at a cost of 3,358,250 francs. The following indications were adopted at a Local Medicines Committee: 1) in adults: hypoalbuminemia associated with edema or ascites; 2) in children: digestive disorders leading secondarily to exsudative enteropathy and/or hypoalbuminemia. Consumption of polyvalent Ig was 69,213 g, i.e. 10,856,722 francs. These products were prescribed in accordance with the directives of the Committee for Evaluation and Distribution of Technological Innovations. Consumption of specific Ig and biological glues may seem modest in relation to that of other products. BDMP expenditure appears particularly heavy here (about 26.5 MF/year) but consensual adoption of therapeutic guidelines has enabled rationalization of prescribing conditions with the best possible consideration of benefit/risk vs costs ratios. Traceability and drug safety monitoring procedures are linked to and integrated in the more global concept of Quality Assurance. Since January 1995, several withdrawals of batches have been recorded because of suspicion (or death due to) Creutzfeld-Jakob, or post-donation HIV seroconversion. In this area, the Hospital Pharmacist acts by the establishment in real time of a permanent safety link between the patient, a prescriber, an indication, a product prescribed and the product actually administered.

A cost analysis of the prevention of end-stage renal disease: immunoglobulin therapy for IgA nephropathy

A cost analysis was used to evaluate three possible immunoglobulin (IgG) treatment protocols for end-stage renal disease due to IgA nephropathy. The perspective chosen for the cost analysis was that of the health-care delivery system. The baseline strategy was the absence of IgG treatment, and alternative strategies corresponded to three protocols presently on trial: all three included a high initial dose of intravenous IgG. Protocol 1 followed with intramuscular IgG injections only, protocol 2 with intramuscular plus intravenous injections, and protocol 3 with intravenous injections only. The costs of treatment included the costs of immunoglobulins, outpatient hospital costs, and the costs of tests; the saving (costs averted) resulted from kidney dialysis averted. The bottom line for the health-care system is a net savings of $233,000, $213,000, or $83,000, depending on the protocol chosen. The computation of costs did not value physical and psychological health benefits. Thus, any subjective benefit, such as improved comfort, or objective benefit, such as longer life expectancy, would be an improvement over the results presented here.

Heterologous antisera and antivenins are essential biologicals: perspectives on a worldwide crisis

Active immunization against infectious disease is important. However, much of our world faces poverty, social injustice, and warfare, all of which cause universal immunization to remain a distant dream. Agents that provide passive immunity thus remain essential biologicals. The most important of these are human or equine antisera against rabies, tetanus, diphtheria, and snake antivenins. Homologous products are either unavailable or unaffordable in places where they are needed the most. Less expensive heterologous (equine) antisera can be purified and are safe to use, but these antisera are also in short supply. Monoclonal antibodies have been developed but are even less likely to be affordable in poor countries. Several traditional sources of equine antisera are becoming depleted as a result of economic disincentives; a poor reputation based on the high adverse reaction rates of the old, unpurified products; and the activities of animal rights activists who object to the use of horses as blood donors. Purified, pepsin-digested equine antisera are preferred; but developing countries sometimes are forced to make crude products that are less safe or have no specific therapy available at all.

Management of the presumed susceptible varicella (chickenpox)-exposed gravida: a cost-effectiveness/cost-benefit analysis

OBJECTIVE

To compare the cost-effectiveness and cost-benefit of different strategies for managing the presumed susceptible varicella (chickenpox)-exposed gravida.

METHODS

Three strategies were evaluated: 1) a do-nothing or observation strategy; 2) a testing strategy, in which immune status was assessed and varicella-zoster immune globulin was administered to those who tested nonimmune; and 3) a universal-administration strategy, in which varicella-zoster immune globulin was given to all exposed, presumed susceptible gravidas. Because precise data are unavailable about varicella mortality and hospitalization rates in pregnancy, a range of potential rates was evaluated, from one to greater than 20 times healthy nonpregnant adult rates. The potential efficacy of varicella-zoster immune globulin varied from 1 to 99%. A strategy was defined as cost-effective if it cost less than $50,000 per life-year gained.

RESULTS

If the mortality rate from varicella infection in pregnancy was increased fivefold over the nonpregnant healthy adult rate (ie, from 31/100,000 to 155/100,000 cases), efficacy would have to be at least 49% for the immune-testing strategy to be cost-effective. If pregnancy only doubled the varicella mortality rate, then even with perfect efficacy, the immune-testing strategy would not be cost-effective. Under most assumptions, the universal-administration strategy was cost-ineffective when compared with the immune-testing strategy. Similar results were obtained in the parallel cost-benefit analysis, which considered hospitalization costs and rates. The analysis was sensitive to the varicella transmission rate and the discount rate.

CONCLUSION

From a cost-effectiveness/cost-benefit standpoint, management based on immune testing is preferable to universal varicella-zoster immune globulin administration when caring for the varicella-exposed gravida with a negative or indeterminate infection history.

Preventing hepatitis A infections in travelers to endemic areas

In 1995, 24 million travelers from the United States are anticipated to visit developing countries where hepatitis A is endemic. Passive immunization with immune globulin, before exposure or within two weeks following exposure to the hepatitis A virus, protects against clinical disease in < 70-90% of immunized individuals. The duration of protection, measured in months, is relatively short. Active immunization with a single dose of inactivated hepatitis A virus vaccine appears to provide greater protective efficacy and, based on the persistence of vaccine-induced protective antibodies, should provide protection for years. Booster doses given between six and 12 months are likely to provide immunity that may persist for at least a decade. The inactivated hepatitis A vaccine approved for use in the United States has been clinically well-tolerated; mild transient soreness at the injection site is the most frequently reported adverse reaction. Immunization with inactivated hepatitis A vaccine is a safe and effective method for travelers to endemic areas to protect themselves against this infection.

Cost effectiveness of hepatitis A prevention in France

A spreadsheet simulation model of hepatitis A disease was developed to evaluate the cost effectiveness of an inactivated [corrected] hepatitis A vaccine ('Havrix', SmithKline Beecham) in high risk groups in France. Gammaglobulin prophylaxis, systematic vaccination without screening and vaccination of nonimmune persons after systematic screening were compared with the reference situation of no prevention over a 10-year period. It was found that both vaccination strategies would prevent 98% of new cases of hepatitis A, and would generate savings of FF4.2 to FF4.7 million ($US1 = FF5, 1995) in alternative service volunteers [initial seroprevalence (IS) 26%] stationed in countries with high hepatitis A endemicity. The cost per symptomatic case avoided [i.e. the cost-effectiveness ratio (CER)] was found to vary from FF177,612 with screening to FF281,463 without screening in adult tourists (IS 77%). In hospital workers, screening before vaccination (CER = FF65,108) would be about half as costly as systematic vaccination (IS 55 to 79%). Recommendations for vaccination should take into account the specific collective or individual risk, age, seroprevalence and probability of compliance with the prevention protocol.