The cost of rabies postexposure prophylaxis: one state's experience.

OBJECTIVE: This study was undertaken to evaluate trends in the use of rabies postexposure prophylaxis (PEP) before, during, and following an epidemic of raccoon rabies in Massachusetts. METHODS: The authors reviewed initiation of PEP as reported to the Massachusetts Department of Public Health (MDPH) from August 1994 to December 1995 and surveyed hospital pharmacies to determine the number of vials of Human Rabies Immune Globulin (HRIG) dispensed from 1991 through 1995 and charges to patients per vial. RESULTS: PEP use increased dramatically, from 1.7 per 100,000 population in 1991 (pre-epidemic) to 45 per 100,000 in 1995 (after the first stages of the epidemic). The median costs per patient for biologics was $1646 (range: $632-$3435). Including physician and emergency room charges, per-patient median costs were $2376 (range: $1038-$4447). Total health care charges for PEP in Massachusetts in 1995 were estimated at $2.4 million to $6.4 million. CONCLUSIONS: Given the rapid increase in use of PEP, further studies should be undertaken to determine the appropriateness of use, and other alternatives, such as oral wildlife vaccines, should be considered.

Human contact with bait containing vaccine for control of rabies in wildlife.

OBJECTIVE: To document the number of human contacts with bait containing liquid vaccinia-rabies glycoprotein (V-RG) vaccine, to evaluate factors that might affect human contact with bait-vaccine units, and to summarize adverse reactions in people after contact with vaccine. DESIGN: Retrospective 4-year survey of directors of 6 oral rabies vaccination programs. SAMPLE POPULATION: Human residents in areas of vaccination programs. PROCEDURE: Data were collected from report forms and telephone conversations with directors of oral rabies vaccination programs in Florida, Massachusetts, New Jersey, Texas, and New York. Data collected included information regarding human contact with bait and vaccine, sex and age of person involved in contact, human population density, bait density, type of labeling used on bait, and other factors. RESULTS: Human contact with bait was more likely in areas where bait had white labels (vs lettering in black ink) and in areas with high human population densities. Directors of all programs reported that human contact with bait-vaccine units was minimal. Adverse reactions in exposed people were not reported. On the basis of these findings, concerns about V-RG vaccine posing a substantial public health risk remain unfounded. CLINICAL IMPLICATIONS: Directors of oral rabies vaccination programs should systematically collect information about exposures and potential factors affecting exposure of people to bait-vaccine units. People with substantial exposure to V-RG vaccine should be evaluated for immune status and any resulting symptoms should be documented and monitored.

Prevention of the spread of rabies to wildlife by oral vaccination of raccoons in Massachusetts.

OBJECTIVE: To evaluate the use of bait containing rabies vaccine to create a barrier of rabies-vaccinated raccoons in Massachusetts and to determine the effectiveness of various bait distribution strategies in halting the spread of rabies. DESIGN: Prospective study. SAMPLE POPULATION: Free-ranging raccoons. PROCEDURE: Baits were distributed twice yearly in a 207-km2 (80-mi2) area in the vicinity of the Cape Cod Canal. Bait density and distribution strategy varied among 3 treatment areas. Raccoons were caught in live traps after bait distribution and anesthetized; blood samples were obtained to measure serum antibody titers to rabies virus. Vaccination rates were determined by the percentage of captured raccoons with antibody titers to rabies virus > or = 1:5. In addition, raccoons with clinical signs of illness inside the vaccination zone and adjacent areas were euthanatized and submitted for rabies testing. RESULTS: The percentage of vaccinated raccoons differed significantly among the following 3 areas with various bait densities: high-density area with uniform bait distribution (103 baits/km2 [267 baits/mi2]) = 37%; low-density area with additional targeted bait distribution (93 baits/km2 [240 baits/mi2]) = 67%; and, high-density area with additional targeted bait distribution (135 baits/km2 [350 baits/mi2]) = 77%. Nineteen animals with rabies (15 raccoons, 3 skunks, 1 cat) were reported in the area just outside of the vaccination zone, but only 1 raccoon with rabies was reported from inside the vaccination zone. CLINICAL IMPLICATIONS: In this suburban study area, an approximate vaccination rate of 63% was sufficient to halt the spread of rabies in free-ranging raccoons. Compared with uniform bait distribution, targeting raccoon habitats increased vaccination rates.

Knowledge and attitudes of residents in two areas of Massachusetts about rabies and an oral vaccination program in wildlife.

OBJECTIVE: To compare public knowledge and attitudes about rabies and an oral rabies vaccination program in raccoons. DESIGN: Random-digit dial telephone survey. SAMPLE POPULATION: Residents of 2 areas of Massachusetts. PROCEDURE: Residents of 2 areas of Massachusetts were called to participate in a telephone survey. One area (Cape Ann) included 8 towns, most of which have had rabies in raccoons since 1993. The second area (Cape Cod) included 7 towns, 5 of which have not had rabies in raccoons. Calls were made to 642 persons, and of these, 265 agreed to participate in the survey. Of the nonrespondents who were subsequently contacted again, half agreed to participate. Data were analyzed using a statistical program. Fisher's exact and chi 2 tests were used to determine associations. RESULTS: Residents from the area virtually free of rabies in raccoons were significantly less likely to consider rabies as a potential health threat for children in their household. The perception of rabies as a threat was higher for residents in the endemic area. Residents in both areas considered rabies control to be a high priority and supported use of state funding for an oral vaccination program. CLINICAL IMPLICATIONS: People recognize dangers associated with rabies and believe that oral vaccination programs will decrease the risk of exposure.

Health insurance coverage and outcome following acute myocardial infarction. A community-wide perspective.

BACKGROUND: Several studies have suggested that type of medical insurance coverage is associated with hospital utilization rates and receipt of selected diagnostic or treatment approaches. To our knowledge no studies, however, have examined the relation between medical insurance coverage and short-term outcomes following acute myocardial infarction (AMI) from a multihospital, community-wide perspective. OBJECTIVE: To examine the association between medical insurance coverage and in-hospital case-fatality rates as well as length of hospital stay following AMI. METHODS: The study sample consisted of 3735 residents of the Worcester, Mass, metropolitan area hospitalized with validated AMI during 1986, 1988, 1990, 1991, and 1993 at all metropolitan Worcester hospitals. Data were obtained from the review of medical records. Patients were stratified into 5 medical insurance groups for purposes of analysis: private or commercial (n = 711), Medicaid (n = 101), Medicare (n = 1991), health maintenance organization (n = 741), and self-pay or other (n = 191). Crude and multivariable-adjusted analyses were used to examine the relation between medical insurance coverage and length of hospital stay and in-hospital case-fatality rates following AMI. RESULTS: In-hospital case-fatality rates during the period under study were 7.7%, 11.9%, 21.4%, 9.3%, and 10.0% in the 5 medical insurance groups, respectively. After adjusting for several factors that may affect in-hospital mortality, relative to the referent group of private or commercial insurance patients (odds ratio, 1.0), the multivariable-adjusted odds for dying during the acute hospitalization were 0.87 (95% confidence interval [CI], 0.56-1.36) for health maintenance organization patients, 1.22 (95% CI, 0.55-2.68) for Medical patients, 1.25 (95% CI, 0.85-1.84) for Medicare patients, and 1.21 (95% CI, 0.60-2.44) for self-pay or other patients. The mean length of hospitalization after excluding patients with a prolonged hospitalization was 10.1 days for private or commercial insurance patients, 9.4 days for health maintenance organization patients, 10.9 days for Medicaid patients, 11.1 days for Medicare patients, and 9.8 days for self-pay or other patients. No significant differences in the average duration of hospitalization were seen between the medical insurance groups after controlling for potential confounding variables. CONCLUSIONS: The results of this population-based study suggest that patient insurance status is not significantly associated with either length of hospital stay or short-term mortality following AMI. Other demographic and clinical prognostic factors appear to be more important predictors of short-term outcome in this patient population.