TREATMENT AND VACCINATION STRATEGIES TO CONTROL CHOLERA IN SUB-SAHARAN REFUGEE SETTINGS - A COST-EFFECTIVENESS ANALYSIS

Context.-There is significant controversy about how best to control ch olera epidemics in refugee settings. Specifically, there is marked dis agreement about whether to use oral cholera vaccines in these settings , despite the improved safety and effectiveness profiles of these vacc ines. Objective.-To determine the cost-effectiveness of alternative in tervention strategies, including vaccination, to control cholera outbr eaks in sub-Saharan refugee camps. Design.-A cost-effectiveness analys is based on probabilities of cholera outcomes derived from epidemiolog ic data compiled for refugee settings in Malawi from 1987 through 1993 ; data for costs were obtained from a large relief agency that provide s medical care in such settings. Setting and Participants.-A hypotheti cal refugee camp with 50 000 persons in sub-Saharan Africa evaluated f or a 2-year period. Interventions.-We compared the costs and outcomes of alternative strategies in which appropriate rehydration therapy for cholera is introduced preemptively (at the establishment of a camp) o r reactively (once an epidemic is recognized) and in which mass immuni zation with oral B subunit killed whole-cell (BS-WC) cholera vaccine i s added to a rehydration program either preemptively or reactively. Ma in Outcome Measures.-Cost per cholera case prevented and cost per chol era death averted. Results.-In a situation with no available rehydrati on therapy suitable for the management of severe cholera, a strategy o f preemptive therapy ($320 per death averted) costs less and is more e ffective than a strategy of reactive therapy ($586 per death averted). Adding vaccination to preemptive therapy is expensive: $1745 per addi tional death averted for preemptive vaccination and $3833 per addition al death averted for reactive vaccination. However, if the cost of vac cine falls below $0.22 per dose, strategies combining vaccination and preemptive therapy become more cost-effective than therapy alone. Conc lusions.-Provision for managing cholera outbreaks at the inception of a refugee camp (preemptive therapy) is the most cost-effective strateg y for controlling cholera outbreaks in sub-Saharan refugee settings. S hould the price of BS-WC cholera vaccine fall below $0.22 per dose, ho wever, supplementation of preemptive therapy with mass vaccination wil l become a cost-effective option.