| Background and objectiveRabies is an acute animal-borne infectious disease caused by Rabies Virus(RV).Rabies virus invades human body mainly through damaged skin or mucosa.Its clinical manifestations are typically feared of wind,water,pharyngeal muscle spasm,progressive paralysis,etc.It should differ from epidemic encephalitis and poliomyelitis.Rabies is one of the diseases with the highest mortality rate.As long as symptoms occur,almost 100% of all deaths occur.Post-exposure prophylactic(PEP)is the only effective way to prevent rabies after a dog bite.The production of vaccines exist to prevent human rabies and canine rabies,however 60,000 people still die of rabies every year in the world,resulting in an economic burden of about US$4 billion,which brings serious disease burden to patients,families and society.This also poses a challenge for formulating reasonable strategies for rabies prevention,control and elimination.Therefore,this study intends to evaluate the disease burden of patients bitten by dogs in Jiangsu Province by means of literature search,field investigation and expert interviews,and construct a dog-dog and dog-human system dynamics model combined with decision tree model to evaluate the health economics effects of different intervention strategies for rabies elimination,and then to make suggestions for the customization of rabies prevention and control strategies in China.Methods(1)In this study,the outpatient cases of dog bite in Changshu District of Suzhou City,Sheyang County of Yancheng City and Dongtai City of Jiangsu Province from 2016 to 2018 were taken as the research objects.After obtaining the informed consent of the patients or their guardians,the direct economic burden,quality adjusted life years and other information of the outpatient patients with dog bite were collected through a unified questionnaire.(2)Based on the relevant links of rabies transmission between dogs and people,the natural history of rabies disease,epidemiological investigation and the experience of medical experts,the system dynamics model of dog-dog and dog-human transmission is constructed.Based on literature review,expert consultation and field investigation,the relevant parameters of the model are estimated.Vensim PLE software was used to simulate the epidemic transmission with or without intervention measures(3)Decision-tree model was used to evaluate the health economic effect of PEP measures under different vaccination coverage of canine vaccination from a social perspective.Incremental cost-effectiveness ratio and incremental cost-utility ratio were used to determine the dominant strategy,and the sensitivity parameters of the model are determined by one-way sensitivity analysis,two-way sensitivity analysis and probability sensitivity analysis.Results(1)76.50% of 1354 patients got married and 43.06% got rural cooperative medical service.The direct economic burden of 1354 outpatients bitten by dogs were?609421.86,averaged ?450.09.The difference of per capita total economic burden in different regions,different marital status,different type of medical insurance and annual income of different families had statistical significance.Multiple linear stepwise regression analysis of the total economic burden of outpatient patients with dog bite showed that the influence of regional and family income variables on the total economic burden of patients with dog bite had statistical significance.The EQ-5D utility value of 413 patients with dog bite was 357.66 quality-adjusted life years(QALY),and the average EQ-5D utility value was 0.87 QALY.The difference of QALY in different exposure categories was statistically significant.The QALY of patients with category-? exposure was higher than that of patients with category-? exposure.(2)A dynamic model of susceptible-exposure-infections-recovered(SEIR)for rabies transmission between dogs and human was constructed.On the basis of the basic model,the SEIR model for classified cross-infection of stray and domestic dogs was determined to better reflect the transmission process of rabies in the population.The model of canine population classification and cross infection can better simulate the spread of rabies in dogs and human.The goodness of fit between the model simulation data and the actual data is 0.89.Sensitivity analysis showed that dog recruitment rate,the infection coefficient between domestic and stray dogs were the sensitive factors of the dynamic model.(3)From a social point of view,compared with the current immunization strategy(43% vaccination coverage of canine,combined with human rabies vaccines for category-? exposure and vaccines with RIG for category-? exposure),70% vaccination coverage of canine was the optimal strategy;if human vaccination is considered,55% vaccination coverage of canine combined with vaccines for human category-? exposure was the optimal strategy.The probability that an injured dog carries rabies virus is the most sensitive parameter.When it is greater than 0.00503,the combination of category-? exposure vaccination/category-? exposure vaccination with RIG is the optimal strategy.When it is between 0.0012 and 0.00503,vaccination of category-?/? exposure is the optimal strategy;when it was less than 0.00082,vaccination of category-? exposure is the optimal strategy;when it is between 0.00082 and 0.0012,vaccination with RIG of category-? exposure is the optimal strategy.The probability that an injured dog carries rabies virus is one of the important factors affecting the strategy of rabies prevention and control.Conclusions(1)The disease burden of dog bites is serious,and affected by region,sex and age,which brings economic burden to society and patients,but also affects the quality of life of patients.(2)The dynamic and decision-tree coupling model preliminarily found that the goal of eliminating dog-mediated human rabies could be achieved by strengthening the management of stray dogs,reducing cross-infection between domestic dogs and stray dogs,increasing the vaccination rate of dogs and intensifying vaccination after human exposure. |
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