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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Cost-Effectiveness of Antivenoms for Snakebite Envenoming in 16 Countries in West Africa</title><author><name sortKey="Hamza, Muhammad" sort="Hamza, Muhammad" uniqKey="Hamza M" first="Muhammad" last="Hamza">Muhammad Hamza</name><affiliation><nlm:aff id="aff001"><addr-line>College of Health of Sciences, Bayero University, Kano, Nigeria</addr-line></nlm:aff></affiliation></author><author><name sortKey="Idris, Maryam A" sort="Idris, Maryam A" uniqKey="Idris M" first="Maryam A." last="Idris">Maryam A. Idris</name><affiliation><nlm:aff id="aff001"><addr-line>College of Health of Sciences, Bayero University, Kano, Nigeria</addr-line></nlm:aff></affiliation></author><author><name sortKey="Maiyaki, Musa B" sort="Maiyaki, Musa B" uniqKey="Maiyaki M" first="Musa B." last="Maiyaki">Musa B. Maiyaki</name><affiliation><nlm:aff id="aff001"><addr-line>College of Health of Sciences, Bayero University, Kano, Nigeria</addr-line></nlm:aff></affiliation></author><author><name sortKey="Lamorde, Mohammed" sort="Lamorde, Mohammed" uniqKey="Lamorde M" first="Mohammed" last="Lamorde">Mohammed Lamorde</name><affiliation><nlm:aff id="aff002"><addr-line>Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda</addr-line></nlm:aff></affiliation></author><author><name sortKey="Chippaux, Jean Philippe" sort="Chippaux, Jean Philippe" uniqKey="Chippaux J" first="Jean-Philippe" last="Chippaux">Jean-Philippe Chippaux</name><affiliation><nlm:aff id="aff003"><addr-line>Institut de Recherche pour le Development, Cotonou, Benin Republic and Université Paris Descartes, Sorbonne Paris Cité, Faculté de Pharmacie, Paris, France</addr-line></nlm:aff></affiliation></author><author><name sortKey="Warrell, David A" sort="Warrell, David A" uniqKey="Warrell D" first="David A." last="Warrell">David A. Warrell</name><affiliation><nlm:aff id="aff004"><addr-line>Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Kuznik, Andreas" sort="Kuznik, Andreas" uniqKey="Kuznik A" first="Andreas" last="Kuznik">Andreas Kuznik</name><affiliation><nlm:aff id="aff001"><addr-line>College of Health of Sciences, Bayero University, Kano, Nigeria</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff002"><addr-line>Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff005"><addr-line>Celgene Corporation, Warren, New Jersey, United States of America</addr-line></nlm:aff></affiliation></author><author><name sortKey="Habib, Abdulrazaq G" sort="Habib, Abdulrazaq G" uniqKey="Habib A" first="Abdulrazaq G." last="Habib">Abdulrazaq G. Habib</name><affiliation><nlm:aff id="aff001"><addr-line>College of Health of Sciences, Bayero University, Kano, Nigeria</addr-line></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27027633</idno><idno type="pmc">4814077</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4814077</idno><idno type="RBID">PMC:4814077</idno><idno type="doi">10.1371/journal.pntd.0004568</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">000400</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000400</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Cost-Effectiveness of Antivenoms for Snakebite Envenoming in 16 Countries in West Africa</title><author><name sortKey="Hamza, Muhammad" sort="Hamza, Muhammad" uniqKey="Hamza M" first="Muhammad" last="Hamza">Muhammad Hamza</name><affiliation><nlm:aff id="aff001"><addr-line>College of Health of Sciences, Bayero University, Kano, Nigeria</addr-line></nlm:aff></affiliation></author><author><name sortKey="Idris, Maryam A" sort="Idris, Maryam A" uniqKey="Idris M" first="Maryam A." last="Idris">Maryam A. Idris</name><affiliation><nlm:aff id="aff001"><addr-line>College of Health of Sciences, Bayero University, Kano, Nigeria</addr-line></nlm:aff></affiliation></author><author><name sortKey="Maiyaki, Musa B" sort="Maiyaki, Musa B" uniqKey="Maiyaki M" first="Musa B." last="Maiyaki">Musa B. Maiyaki</name><affiliation><nlm:aff id="aff001"><addr-line>College of Health of Sciences, Bayero University, Kano, Nigeria</addr-line></nlm:aff></affiliation></author><author><name sortKey="Lamorde, Mohammed" sort="Lamorde, Mohammed" uniqKey="Lamorde M" first="Mohammed" last="Lamorde">Mohammed Lamorde</name><affiliation><nlm:aff id="aff002"><addr-line>Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda</addr-line></nlm:aff></affiliation></author><author><name sortKey="Chippaux, Jean Philippe" sort="Chippaux, Jean Philippe" uniqKey="Chippaux J" first="Jean-Philippe" last="Chippaux">Jean-Philippe Chippaux</name><affiliation><nlm:aff id="aff003"><addr-line>Institut de Recherche pour le Development, Cotonou, Benin Republic and Université Paris Descartes, Sorbonne Paris Cité, Faculté de Pharmacie, Paris, France</addr-line></nlm:aff></affiliation></author><author><name sortKey="Warrell, David A" sort="Warrell, David A" uniqKey="Warrell D" first="David A." last="Warrell">David A. Warrell</name><affiliation><nlm:aff id="aff004"><addr-line>Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Kuznik, Andreas" sort="Kuznik, Andreas" uniqKey="Kuznik A" first="Andreas" last="Kuznik">Andreas Kuznik</name><affiliation><nlm:aff id="aff001"><addr-line>College of Health of Sciences, Bayero University, Kano, Nigeria</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff002"><addr-line>Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff005"><addr-line>Celgene Corporation, Warren, New Jersey, United States of America</addr-line></nlm:aff></affiliation></author><author><name sortKey="Habib, Abdulrazaq G" sort="Habib, Abdulrazaq G" uniqKey="Habib A" first="Abdulrazaq G." last="Habib">Abdulrazaq G. Habib</name><affiliation><nlm:aff id="aff001"><addr-line>College of Health of Sciences, Bayero University, Kano, Nigeria</addr-line></nlm:aff></affiliation></author></analytic><series><title level="j">PLoS Neglected Tropical Diseases</title><idno type="ISSN">1935-2727</idno><idno type="eISSN">1935-2735</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="sec001"><title>Background</title><p>Snakebite poisoning is a significant medical problem in agricultural societies in Sub Saharan Africa. Antivenom (AV) is the standard treatment, and we assessed the cost-effectiveness of making it available in 16 countries in West Africa.</p></sec><sec id="sec002"><title>Methods</title><p>We determined the cost-effectiveness of AV based on a decision-tree model from a public payer perspective. Specific AVs included in the model were Antivipmyn, FAV Afrique, EchiTab-G and EchiTab-Plus. We derived inputs from the literature which included: type of snakes causing bites (carpet viper (<italic>Echis</italic> species)/non-carpet viper), AV effectiveness against death, mortality without AV, probability of Early Adverse Reactions (EAR), likelihood of death from EAR, average age at envenomation in years, anticipated remaining life span and likelihood of amputation. Costs incurred by the victims include: costs of confirming and evaluating envenomation, AV acquisition, routine care, AV transportation logistics, hospital admission and related transportation costs, management of AV EAR compared to the alternative of free snakebite care with ineffective or no AV. Incremental Cost Effectiveness Ratios (ICERs) were assessed as the cost per death averted and the cost per Disability-Adjusted-Life-Years (DALY) averted. Probabilistic Sensitivity Analyses (PSA) using Monte Carlo simulations were used to obtain 95% Confidence Intervals of ICERs.</p></sec><sec id="sec003"><title>Results</title><p>The cost/death averted for the 16 countries of interest ranged from $1,997 in Guinea Bissau to $6,205 for Liberia and Sierra Leone. The cost/DALY averted ranged from $83 (95% Confidence Interval: $36-$240) for Benin Republic to $281 ($159–457) for Sierra-Leone. In all cases, the base-case cost/DALY averted estimate fell below the commonly accepted threshold of one time per capita GDP, suggesting that AV is highly cost-effective for the treatment of snakebite in all 16 WA countries. The findings were consistent even with variations of inputs in 1—way sensitivity analyses. In addition, the PSA showed that in the majority of iterations ranging from 97.3% in Liberia to 100% in Cameroun, Guinea Bissau, Mali, Nigeria and Senegal, our model results yielded an ICER that fell below the threshold of one time per capita GDP, thus, indicating a high degree of confidence in our results.</p></sec><sec id="sec004"><title>Conclusions</title><p>Therapy for SBE with AV in countries of WA is highly cost-effective at commonly accepted thresholds. Broadening access to effective AVs in rural communities in West Africa is a priority.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Warrell, Da" uniqKey="Warrell D">DA Warrell</name></author><author><name sortKey="Arnett, C" uniqKey="Arnett C">C Arnett</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Visser, L E" uniqKey="Visser L">L.E. Visser</name></author><author><name sortKey="Kyei Faried, S" uniqKey="Kyei Faried S">S. Kyei-Faried</name></author><author><name sortKey="Belcher, D W" uniqKey="Belcher D">D.W. Belcher</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Enwere, Gc" uniqKey="Enwere G">GC Enwere</name></author><author><name sortKey="Obu, Ha" uniqKey="Obu H">HA Obu</name></author><author><name sortKey="Jobarteh, A" uniqKey="Jobarteh A">A Jobarteh</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Fayomi, B" uniqKey="Fayomi B">B Fayomi</name></author><author><name sortKey="Massougbodji, A" uniqKey="Massougbodji A">A Massougbodji</name></author><author><name sortKey="Chobli, M" uniqKey="Chobli M">M Chobli</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Trape, Jf" uniqKey="Trape J">JF Trape</name></author><author><name sortKey="Pison, G" uniqKey="Pison G">G Pison</name></author><author><name sortKey="Guyavarch, E" uniqKey="Guyavarch E">E Guyavarch</name></author><author><name sortKey="Mane, Y" uniqKey="Mane Y">Y Mane</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chippaux, Jp" uniqKey="Chippaux J">JP Chippaux</name></author><author><name sortKey="Massougbodji, A" uniqKey="Massougbodji A">A Massougbodji</name></author><author><name sortKey="Stock, Rp" uniqKey="Stock R">RP Stock</name></author><author><name sortKey="Alagon, A" uniqKey="Alagon A">A Alagon</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chippaux, J P" uniqKey="Chippaux J">J-P Chippaux</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kasturiratne, A" uniqKey="Kasturiratne A">A Kasturiratne</name></author><author><name sortKey="Wickremasinghe, Ar" uniqKey="Wickremasinghe A">AR Wickremasinghe</name></author><author><name sortKey="De Silva, Nr" uniqKey="De Silva N">NR de Silva</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pugh, Rnh" uniqKey="Pugh R">RNH Pugh</name></author><author><name sortKey="Theakston, Rdg" uniqKey="Theakston R">RDG Theakston</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Warrell, Da" uniqKey="Warrell D">DA Warrell</name></author><author><name sortKey="Davidson, Nmcd" uniqKey="Davidson N">NMcD Davidson</name></author><author><name sortKey="Greenwood, Bm" uniqKey="Greenwood B">BM Greenwood</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Meyer, Wp" uniqKey="Meyer W">WP Meyer</name></author><author><name sortKey="Habib, Ag" uniqKey="Habib A">AG Habib</name></author><author><name sortKey="Onayade, Aa" uniqKey="Onayade A">AA Onayade</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Warrell, Da" uniqKey="Warrell D">DA Warrell</name></author><author><name sortKey="Barnes, Hj" uniqKey="Barnes H">HJ Barnes</name></author><author><name sortKey="Pirburn, Mf" uniqKey="Pirburn M">MF Pirburn</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Pugh, Rnh" uniqKey="Pugh R">RNH Pugh</name></author><author><name sortKey="Theakston, Rdg" uniqKey="Theakston R">RDG Theakston</name></author><author><name sortKey="Reid, Ha" uniqKey="Reid H">HA Reid</name></author><author><name sortKey="Bhar, Is" uniqKey="Bhar I">IS Bhar</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Muguti, Gi" uniqKey="Muguti G">GI Muguti</name></author><author><name sortKey="Maramba, A" uniqKey="Maramba A">A Maramba</name></author><author><name sortKey="Washaya, Ct" uniqKey="Washaya C">CT Washaya</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Warrell, Da" uniqKey="Warrell D">DA Warrell</name></author><author><name sortKey="Ormerod, Ld" uniqKey="Ormerod L">LD Ormerod</name></author><author><name sortKey="Davidson, Nmcd" uniqKey="Davidson N">NMcD Davidson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Warrell, Da" uniqKey="Warrell D">DA Warrell</name></author><author><name sortKey="Ormerod, Ld" uniqKey="Ormerod L">LD Ormerod</name></author><author><name sortKey="Davidson, Nmcd" uniqKey="Davidson N">NMcD Davidson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Warrell, Da" uniqKey="Warrell D">DA Warrell</name></author><author><name sortKey="Greenwood, Bm" uniqKey="Greenwood B">BM Greenwood</name></author><author><name sortKey="Davidson, Nmcd" uniqKey="Davidson N">NMcD Davidson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Warrell, Da" uniqKey="Warrell D">DA Warrell</name></author><author><name sortKey="Ormerod, Ld" uniqKey="Ormerod L">LD Ormerod</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mustapha, Sk" uniqKey="Mustapha S">SK Mustapha</name></author><author><name sortKey="Mubi, Bm" uniqKey="Mubi B">BM Mubi</name></author><author><name sortKey="Askira, Bh" uniqKey="Askira B">BH Askira</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Habib, Ag" uniqKey="Habib A">AG Habib</name></author><author><name sortKey="Abubakar, Sb" uniqKey="Abubakar S">SB Abubakar</name></author><author><name sortKey="Abubakar, Is" uniqKey="Abubakar I">IS Abubakar</name></author><author><name sortKey="Larnyang, S" uniqKey="Larnyang S">S Larnyang</name></author><author><name sortKey="Durfa, N" uniqKey="Durfa N">N Durfa</name></author><author><name sortKey="Nasidi, A" uniqKey="Nasidi A">A Nasidi</name></author><author><name sortKey="Yusuf, Po" uniqKey="Yusuf P">PO Yusuf</name></author><author><name sortKey="Garnvwa, J" uniqKey="Garnvwa J">J Garnvwa</name></author><author><name sortKey="Theakston, Rdg" uniqKey="Theakston R">RDG Theakston</name></author><author><name sortKey="Salako, L" uniqKey="Salako L">L Salako</name></author><author><name sortKey="Warrell, Da" uniqKey="Warrell D">DA Warrell</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Williams, Ss" uniqKey="Williams S">SS Williams</name></author><author><name sortKey="Wijesinghe, Ca" uniqKey="Wijesinghe C">CA Wijesinghe</name></author><author><name sortKey="Jayamanne, Sf" uniqKey="Jayamanne S">SF Jayamanne</name></author><author><name sortKey="Buckley, Na" uniqKey="Buckley N">NA Buckley</name></author><author><name sortKey="Dawson, Ah" uniqKey="Dawson A">AH Dawson</name></author><author><name sortKey="Lalloo, Dg" uniqKey="Lalloo D">DG Lalloo</name></author><author><name sortKey="De Silva, Hj" uniqKey="De Silva H">HJ de Silva</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Habib, Ag" uniqKey="Habib A">AG Habib</name></author><author><name sortKey="Warrell, Da" uniqKey="Warrell D">DA Warrell</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Abubakar, Is" uniqKey="Abubakar I">IS Abubakar</name></author><author><name sortKey="Abubakar, Sb" uniqKey="Abubakar S">SB Abubakar</name></author><author><name sortKey="Habib, Ag" uniqKey="Habib A">AG Habib</name></author><author><name sortKey="Nasidi, A" uniqKey="Nasidi A">A Nasidi</name></author><author><name sortKey="Durfa, N" uniqKey="Durfa N">N Durfa</name></author><author><name sortKey="Yusuf, Po" uniqKey="Yusuf P">PO Yusuf</name></author><author><name sortKey="Larnyang, S" uniqKey="Larnyang S">S Larnyang</name></author><author><name sortKey="Garnvwa, J" uniqKey="Garnvwa J">J Garnvwa</name></author><author><name sortKey="Sokomba, E" uniqKey="Sokomba E">E Sokomba</name></author><author><name sortKey="Salako, L" uniqKey="Salako L">L Salako</name></author><author><name sortKey="Theakston, Rd" uniqKey="Theakston R">RD Theakston</name></author><author><name sortKey="Juszczak, E" uniqKey="Juszczak E">E Juszczak</name></author><author><name sortKey="Alder, N" uniqKey="Alder N">N Alder</name></author><author><name sortKey="Warrell, Da" uniqKey="Warrell D">DA Warrell</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Williams, Dj" uniqKey="Williams D">DJ Williams</name></author><author><name sortKey="Jensen, Sd" uniqKey="Jensen S">SD Jensen</name></author><author><name sortKey="Nimorakiotakis, B" uniqKey="Nimorakiotakis B">B Nimorakiotakis</name></author><author><name sortKey="Muller, R" uniqKey="Muller R">R Müller</name></author><author><name sortKey="Winkel, Kd" uniqKey="Winkel K">KD Winkel</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Habib, Ag" uniqKey="Habib A">AG Habib</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="De Silva, Ha" uniqKey="De Silva H">HA de Silva</name></author><author><name sortKey="Pathmeswaran, A" uniqKey="Pathmeswaran A">A Pathmeswaran</name></author><author><name sortKey="Ranasinha, Cd" uniqKey="Ranasinha C">CD Ranasinha</name></author><author><name sortKey="Jayamanne, S" uniqKey="Jayamanne S">S Jayamanne</name></author><author><name sortKey="Samarakoon, Snakebite" uniqKey="Samarakoon S">snakebite Samarakoon</name></author><author><name sortKey="Hittharage, A" uniqKey="Hittharage A">A Hittharage</name></author><author><name sortKey="Kalupahana, R" uniqKey="Kalupahana R">R Kalupahana</name></author><author><name sortKey="Ratnatilaka, Ga" uniqKey="Ratnatilaka G">GA Ratnatilaka</name></author><author><name sortKey="Uluwatthage, W" uniqKey="Uluwatthage W">W Uluwatthage</name></author><author><name sortKey="Aronson, Jk" uniqKey="Aronson J">JK Aronson</name></author><author><name sortKey="Armitage, Jm" uniqKey="Armitage J">JM Armitage</name></author><author><name sortKey="Lalloo, Dg" uniqKey="Lalloo D">DG Lalloo</name></author><author><name sortKey="De Silva, Hj" uniqKey="De Silva H">HJ de Silva</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Brown, Ni" uniqKey="Brown N">NI Brown</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Drame, Bs" uniqKey="Drame B">BS Dramé</name></author><author><name sortKey="Dabo, M" uniqKey="Dabo M">M Dabo</name></author><author><name sortKey="Diani, N" uniqKey="Diani N">N Diani</name></author><author><name sortKey="Cisse, B" uniqKey="Cisse B">B Cissé</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Chippaux, Jp" uniqKey="Chippaux J">JP Chippaux</name></author><author><name sortKey="Habib, Ag" uniqKey="Habib A">AG Habib</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Habib, Ag" uniqKey="Habib A">AG Habib</name></author><author><name sortKey="Lamorde, M" uniqKey="Lamorde M">M Lamorde</name></author><author><name sortKey="Dalhat, Mm" uniqKey="Dalhat M">MM Dalhat</name></author><author><name sortKey="Habib, Zg" uniqKey="Habib Z">ZG Habib</name></author><author><name sortKey="Kuznik, A" uniqKey="Kuznik A">A Kuznik</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Morais, V" uniqKey="Morais V">V Morais</name></author><author><name sortKey="Massaldi, H" uniqKey="Massaldi H">H Massaldi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Brown, N" uniqKey="Brown N">N Brown</name></author><author><name sortKey="Landon, J" uniqKey="Landon J">J Landon</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chippaux, Jp" uniqKey="Chippaux J">JP Chippaux</name></author><author><name sortKey="Lang, J" uniqKey="Lang J">J Lang</name></author><author><name sortKey="Amadi Eddine, S" uniqKey="Amadi Eddine S">S Amadi-Eddine</name></author><author><name sortKey="Fagot, P" uniqKey="Fagot P">P Fagot</name></author><author><name sortKey="Le Mener, V" uniqKey="Le Mener V">V Le Mener</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Balde, Mc" uniqKey="Balde M">MC Baldé</name></author><author><name sortKey="Chippaux, Jp" uniqKey="Chippaux J">JP Chippaux</name></author><author><name sortKey="Boiro, My" uniqKey="Boiro M">MY Boiro</name></author><author><name sortKey="Stock, R" uniqKey="Stock R">R Stock</name></author><author><name sortKey="Massougbodji, A" uniqKey="Massougbodji A">A Massougbodji</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Habib, Ag" uniqKey="Habib A">AG Habib</name></author><author><name sortKey="Abubakar, Sb" uniqKey="Abubakar S">SB Abubakar</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bregani, Er" uniqKey="Bregani E">ER Bregani</name></author><author><name sortKey="Cantoni, F" uniqKey="Cantoni F">F Cantoni</name></author><author><name sortKey="Tantardini, F" uniqKey="Tantardini F">F Tantardini</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Visser, Le" uniqKey="Visser L">LE Visser</name></author><author><name sortKey="Kyei Faried, S" uniqKey="Kyei Faried S">S Kyei-Faried</name></author><author><name sortKey="Belcher, Dw" uniqKey="Belcher D">DW Belcher</name></author><author><name sortKey="Geelhoed, Dw" uniqKey="Geelhoed D">DW Geelhoed</name></author><author><name sortKey="Van Leeuwen, Js" uniqKey="Van Leeuwen J">JS van Leeuwen</name></author><author><name sortKey="Van Roosmalen, J" uniqKey="Van Roosmalen J">J van Roosmalen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Drame, Bs" uniqKey="Drame B">BS Dramé</name></author><author><name sortKey="Diarra, A" uniqKey="Diarra A">A Diarra</name></author><author><name sortKey="Diani, N" uniqKey="Diani N">N Diani</name></author><author><name sortKey="Dabo, A" uniqKey="Dabo A">A Dabo</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Balde, Mc" uniqKey="Balde M">MC Baldé</name></author><author><name sortKey="Chippaux, Jp" uniqKey="Chippaux J">JP Chippaux</name></author><author><name sortKey="Boiro, My" uniqKey="Boiro M">MY Boiro</name></author><author><name sortKey="Stock, Rp" uniqKey="Stock R">RP Stock</name></author><author><name sortKey="Massougbodji, A" uniqKey="Massougbodji A">A Massougbodji</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Laohawiriyakamol, S" uniqKey="Laohawiriyakamol S">S Laohawiriyakamol</name></author><author><name sortKey="Sangkhathat, S" uniqKey="Sangkhathat S">S Sangkhathat</name></author><author><name sortKey="Chiengkriwate, P" uniqKey="Chiengkriwate P">P Chiengkriwate</name></author><author><name sortKey="Patrapinyokul, S" uniqKey="Patrapinyokul S">S Patrapinyokul</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Yates, Vm" uniqKey="Yates V">VM Yates</name></author><author><name sortKey="Lebas, E" uniqKey="Lebas E">E Lebas</name></author><author><name sortKey="Orpiay, R" uniqKey="Orpiay R">R Orpiay</name></author><author><name sortKey="Bale, Bj" uniqKey="Bale B">BJ Bale</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Adehossi, E" uniqKey="Adehossi E">E Adehossi</name></author><author><name sortKey="Sani, R" uniqKey="Sani R">R Sani</name></author><author><name sortKey="Boukari Bawa, M" uniqKey="Boukari Bawa M">M Boukari-Bawa</name></author><author><name sortKey="Niaouro, S" uniqKey="Niaouro S">S Niaouro</name></author><author><name sortKey="Gbaguidi, F" uniqKey="Gbaguidi F">F Gbaguidi</name></author><author><name sortKey="Abdou, I" uniqKey="Abdou I">I Abdou</name></author><author><name sortKey="Parola, P" uniqKey="Parola P">P Parola</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Habib, Ag" uniqKey="Habib A">AG Habib</name></author><author><name sortKey="Kuznik, A" uniqKey="Kuznik A">A Kuznik</name></author><author><name sortKey="Hamza, M" uniqKey="Hamza M">M Hamza</name></author><author><name sortKey="Abdullahi, Mi" uniqKey="Abdullahi M">MI Abdullahi</name></author><author><name sortKey="Chedi, Ba" uniqKey="Chedi B">BA Chedi</name></author><author><name sortKey="Chippaux, Jp" uniqKey="Chippaux J">JP Chippaux</name></author><author><name sortKey="Warrell, Da" uniqKey="Warrell D">DA Warrell</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Hunink, Mg" uniqKey="Hunink M">MG Hunink</name></author><author><name sortKey="Glasziou, P" uniqKey="Glasziou P">P Glasziou</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Fox Rushby, Ja" uniqKey="Fox Rushby J">JA Fox-Rushby</name></author><author><name sortKey="Hanson, K" uniqKey="Hanson K">K Hanson</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Siegel, Je" uniqKey="Siegel J">JE Siegel</name></author><author><name sortKey="Weinstein, Mc" uniqKey="Weinstein M">MC Weinstein</name></author><author><name sortKey="Russell, Lb" uniqKey="Russell L">LB Russell</name></author><author><name sortKey="Gold, Mr" uniqKey="Gold M">MR Gold</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Husereau, D" uniqKey="Husereau D">D Husereau</name></author><author><name sortKey="Drummond, M" uniqKey="Drummond M">M Drummond</name></author><author><name sortKey="Petrou, S" uniqKey="Petrou S">S Petrou</name></author><author><name sortKey="Carswell, C" uniqKey="Carswell C">C Carswell</name></author><author><name sortKey="Moher, D" uniqKey="Moher D">D Moher</name></author><author><name sortKey="Greenberg, D" uniqKey="Greenberg D">D Greenberg</name></author><author><name sortKey="Augustovski, F" uniqKey="Augustovski F">F Augustovski</name></author><author><name sortKey="Briggs, Ah" uniqKey="Briggs A">AH Briggs</name></author><author><name sortKey="Mauskopf, J" uniqKey="Mauskopf J">J Mauskopf</name></author><author><name sortKey="Loder, E" uniqKey="Loder E">E Loder</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Goldie, Sj" uniqKey="Goldie S">SJ Goldie</name></author><author><name sortKey="Yazdanpanah, Y" uniqKey="Yazdanpanah Y">Y Yazdanpanah</name></author><author><name sortKey="Losina, E" uniqKey="Losina E">E Losina</name></author><author><name sortKey="Weinstein, Mc" uniqKey="Weinstein M">MC Weinstein</name></author><author><name sortKey="Anglaret, X" uniqKey="Anglaret X">X Anglaret</name></author><author><name sortKey="Walensky, Rp" uniqKey="Walensky R">RP Walensky</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Long, L" uniqKey="Long L">L Long</name></author><author><name sortKey="Fox, M" uniqKey="Fox M">M Fox</name></author><author><name sortKey="Sanne, I" uniqKey="Sanne I">I Sanne</name></author><author><name sortKey="Rosen, S" uniqKey="Rosen S">S Rosen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Walensky, Rp" uniqKey="Walensky R">RP Walensky</name></author><author><name sortKey="Ross, El" uniqKey="Ross E">EL Ross</name></author><author><name sortKey="Kumarasamy, N" uniqKey="Kumarasamy N">N Kumarasamy</name></author><author><name sortKey="Wood, R" uniqKey="Wood R">R Wood</name></author><author><name sortKey="Noubary, F" uniqKey="Noubary F">F Noubary</name></author><author><name sortKey="Paltiel, D" uniqKey="Paltiel D">D Paltiel</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Van Hoek, Aj" uniqKey="Van Hoek A">AJ van Hoek</name></author><author><name sortKey="Ngama, M" uniqKey="Ngama M">M Ngama</name></author><author><name sortKey="Ismail, A" uniqKey="Ismail A">A Ismail</name></author><author><name sortKey="Chuma, J" uniqKey="Chuma J">J Chuma</name></author><author><name sortKey="Cheburet, S" uniqKey="Cheburet S">S Cheburet</name></author><author><name sortKey="Mutonga, D" uniqKey="Mutonga D">D Mutonga</name></author><author><name sortKey="Kamau, T" uniqKey="Kamau T">T Kamau</name></author><author><name sortKey="Nokes, Dj" uniqKey="Nokes D">DJ Nokes</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Patel, Hd" uniqKey="Patel H">HD Patel</name></author><author><name sortKey="Roberts, Et" uniqKey="Roberts E">ET Roberts</name></author><author><name sortKey="Constela, Do" uniqKey="Constela D">DO Constela</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Goldie, Sj" uniqKey="Goldie S">SJ Goldie</name></author><author><name sortKey="O Hea, M" uniqKey="O Hea M">M O’Shea</name></author><author><name sortKey="Campos, Ng" uniqKey="Campos N">NG Campos</name></author><author><name sortKey="Dias, M" uniqKey="Dias M">M Dias</name></author><author><name sortKey="Sweet, S" uniqKey="Sweet S">S Sweet</name></author><author><name sortKey="Kim, Sy" uniqKey="Kim S">SY Kim</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sinha, A" uniqKey="Sinha A">A Sinha</name></author><author><name sortKey="Levine, O" uniqKey="Levine O">O Levine</name></author><author><name sortKey="Knoll, Md" uniqKey="Knoll M">MD Knoll</name></author><author><name sortKey="Muhib, F" uniqKey="Muhib F">F Muhib</name></author><author><name sortKey="Lieu, Ta" uniqKey="Lieu T">TA Lieu</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">PLoS Negl Trop Dis</journal-id><journal-id journal-id-type="iso-abbrev">PLoS Negl Trop Dis</journal-id><journal-id journal-id-type="publisher-id">plos</journal-id><journal-id journal-id-type="pmc">plosntds</journal-id><journal-title-group><journal-title>PLoS Neglected Tropical Diseases</journal-title></journal-title-group><issn pub-type="ppub">1935-2727</issn><issn pub-type="epub">1935-2735</issn><publisher><publisher-name>Public Library of Science</publisher-name><publisher-loc>San Francisco, CA USA</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27027633</article-id><article-id pub-id-type="pmc">4814077</article-id><article-id pub-id-type="doi">10.1371/journal.pntd.0004568</article-id><article-id pub-id-type="publisher-id">PNTD-D-15-01785</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Organisms</subject><subj-group><subject>Animals</subject><subj-group><subject>Vertebrates</subject><subj-group><subject>Amniotes</subject><subj-group><subject>Reptiles</subject><subj-group><subject>Squamates</subject><subj-group><subject>Snakes</subject><subj-group><subject>Vipers</subject></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Tropical Diseases</subject><subj-group><subject>Neglected Tropical Diseases</subject><subj-group><subject>Snakebite</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Social Sciences</subject><subj-group><subject>Economics</subject><subj-group><subject>Economic Analysis</subject><subj-group><subject>Cost-Effectiveness Analysis</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Anatomy</subject><subj-group><subject>Head</subject><subj-group><subject>Ears</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Anatomy</subject><subj-group><subject>Head</subject><subj-group><subject>Ears</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Anatomy</subject><subj-group><subject>Body Fluids</subject><subj-group><subject>Blood</subject><subj-group><subject>Blood Counts</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Anatomy</subject><subj-group><subject>Body Fluids</subject><subj-group><subject>Blood</subject><subj-group><subject>Blood Counts</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Physiology</subject><subj-group><subject>Body Fluids</subject><subj-group><subject>Blood</subject><subj-group><subject>Blood Counts</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Physiology</subject><subj-group><subject>Body Fluids</subject><subj-group><subject>Blood</subject><subj-group><subject>Blood Counts</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Hematology</subject><subj-group><subject>Blood</subject><subj-group><subject>Blood Counts</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Biology and Life Sciences</subject><subj-group><subject>Organisms</subject><subj-group><subject>Animals</subject><subj-group><subject>Vertebrates</subject><subj-group><subject>Amniotes</subject><subj-group><subject>Reptiles</subject><subj-group><subject>Squamates</subject><subj-group><subject>Snakes</subject></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>People and Places</subject><subj-group><subject>Geographical Locations</subject><subj-group><subject>Africa</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Pharmacology</subject><subj-group><subject>Adverse Reactions</subject></subj-group></subj-group></subj-group></article-categories><title-group><article-title>Cost-Effectiveness of Antivenoms for Snakebite Envenoming in 16 Countries in West Africa</article-title><alt-title alt-title-type="running-head">Cost-Effectiveness of Antivenoms for Snakebite in West Africa</alt-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Hamza</surname><given-names>Muhammad</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Idris</surname><given-names>Maryam A.</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Maiyaki</surname><given-names>Musa B.</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Lamorde</surname><given-names>Mohammed</given-names></name><xref ref-type="aff" rid="aff002"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Chippaux</surname><given-names>Jean-Philippe</given-names></name><xref ref-type="aff" rid="aff003"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Warrell</surname><given-names>David A.</given-names></name><xref ref-type="aff" rid="aff004"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Kuznik</surname><given-names>Andreas</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff002"><sup>2</sup></xref><xref ref-type="aff" rid="aff005"><sup>5</sup></xref></contrib><contrib contrib-type="author"><name><surname>Habib</surname><given-names>Abdulrazaq G.</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="corresp" rid="cor001">*</xref></contrib></contrib-group><aff id="aff001"><label>1</label><addr-line>College of Health of Sciences, Bayero University, Kano, Nigeria</addr-line></aff><aff id="aff002"><label>2</label><addr-line>Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda</addr-line></aff><aff id="aff003"><label>3</label><addr-line>Institut de Recherche pour le Development, Cotonou, Benin Republic and Université Paris Descartes, Sorbonne Paris Cité, Faculté de Pharmacie, Paris, France</addr-line></aff><aff id="aff004"><label>4</label><addr-line>Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom</addr-line></aff><aff id="aff005"><label>5</label><addr-line>Celgene Corporation, Warren, New Jersey, United States of America</addr-line></aff><contrib-group><contrib contrib-type="editor"><name><surname>de Silva</surname><given-names>H Janaka</given-names></name><role>Editor</role><xref ref-type="aff" rid="edit1"></xref></contrib></contrib-group><aff id="edit1"><addr-line>University of Kelaniya, SRI LANKA</addr-line></aff><author-notes><fn fn-type="conflict" id="coi001"><p>At the time of the analysis, AK was employed by Celgene Corporation, with ownership of stock in Celgene Corporation.</p></fn><fn fn-type="con" id="contrib001"><p>Conceived and designed the experiments: AGH AK ML MAI MBM MH DAW JPC. Performed the experiments: AGH AK ML. Analyzed the data: AGH AK ML MAI MBM MH DAW JPC. Contributed reagents/materials/analysis tools: AGH AK ML. Wrote the paper: AGH AK ML MAI MBM MH DAW JPC.</p></fn><corresp id="cor001">* E-mail: <email>abdulrazaq_habib@yahoo.co.uk</email></corresp></author-notes><pub-date pub-type="epub"><day>30</day><month>3</month><year>2016</year></pub-date><pub-date pub-type="collection"><month>3</month><year>2016</year></pub-date><volume>10</volume><issue>3</issue><elocation-id>e0004568</elocation-id><history><date date-type="received"><day>19</day><month>10</month><year>2015</year></date><date date-type="accepted"><day>2</day><month>3</month><year>2016</year></date></history><permissions><copyright-statement>© 2016 Hamza et al</copyright-statement><copyright-year>2016</copyright-year><copyright-holder>Hamza et al</copyright-holder><license xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License</ext-link>, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p></license></permissions><self-uri content-type="pdf" xlink:type="simple" xlink:href="pntd.0004568.pdf"></self-uri><abstract><sec id="sec001"><title>Background</title><p>Snakebite poisoning is a significant medical problem in agricultural societies in Sub Saharan Africa. Antivenom (AV) is the standard treatment, and we assessed the cost-effectiveness of making it available in 16 countries in West Africa.</p></sec><sec id="sec002"><title>Methods</title><p>We determined the cost-effectiveness of AV based on a decision-tree model from a public payer perspective. Specific AVs included in the model were Antivipmyn, FAV Afrique, EchiTab-G and EchiTab-Plus. We derived inputs from the literature which included: type of snakes causing bites (carpet viper (<italic>Echis</italic> species)/non-carpet viper), AV effectiveness against death, mortality without AV, probability of Early Adverse Reactions (EAR), likelihood of death from EAR, average age at envenomation in years, anticipated remaining life span and likelihood of amputation. Costs incurred by the victims include: costs of confirming and evaluating envenomation, AV acquisition, routine care, AV transportation logistics, hospital admission and related transportation costs, management of AV EAR compared to the alternative of free snakebite care with ineffective or no AV. Incremental Cost Effectiveness Ratios (ICERs) were assessed as the cost per death averted and the cost per Disability-Adjusted-Life-Years (DALY) averted. Probabilistic Sensitivity Analyses (PSA) using Monte Carlo simulations were used to obtain 95% Confidence Intervals of ICERs.</p></sec><sec id="sec003"><title>Results</title><p>The cost/death averted for the 16 countries of interest ranged from $1,997 in Guinea Bissau to $6,205 for Liberia and Sierra Leone. The cost/DALY averted ranged from $83 (95% Confidence Interval: $36-$240) for Benin Republic to $281 ($159–457) for Sierra-Leone. In all cases, the base-case cost/DALY averted estimate fell below the commonly accepted threshold of one time per capita GDP, suggesting that AV is highly cost-effective for the treatment of snakebite in all 16 WA countries. The findings were consistent even with variations of inputs in 1—way sensitivity analyses. In addition, the PSA showed that in the majority of iterations ranging from 97.3% in Liberia to 100% in Cameroun, Guinea Bissau, Mali, Nigeria and Senegal, our model results yielded an ICER that fell below the threshold of one time per capita GDP, thus, indicating a high degree of confidence in our results.</p></sec><sec id="sec004"><title>Conclusions</title><p>Therapy for SBE with AV in countries of WA is highly cost-effective at commonly accepted thresholds. Broadening access to effective AVs in rural communities in West Africa is a priority.</p></sec></abstract><abstract abstract-type="summary"><title>Author Summary</title><p>Antivenom is the main intervention against snakebite poisoning but is relatively scarce, unaffordable and the situation has been compounded further by the recent cessation of production of effective antivenoms and marketing of inappropriate products. Given this crisis, we assessed the cost effectiveness of providing antivenoms in West Africa by comparing costs associated with antivenom treatment against their health benefits in decreasing mortality. In the most comprehensive analyses ever conducted, it was observed the incremental cost effectiveness ratio of providing antivenom ranged from $1,997 in Guinea Bissau to $6,205 for Liberia and Sierra-Leone per death averted while cost per Disability Adjusted Life Year (DALY) averted ranged from $83 for Benin Republic to $281 for Sierra-Leone. There is probability of 97.3–100% that antivenoms are very cost-effective in the analyses. These demonstrate antivenom is highly cost-effective and compares favorably to other commonly funded healthcare interventions. Providing and broadening antivenom access throughout areas at risk in rural West Africa should be prioritized given the considerable reduction in deaths and DALYs that could be derived at a relatively small cost.</p></abstract><funding-group><funding-statement>The authors received no specific funding for this work.</funding-statement></funding-group><counts><fig-count count="3"></fig-count><table-count count="3"></table-count><page-count count="16"></page-count></counts><custom-meta-group><custom-meta id="data-availability"><meta-name>Data Availability</meta-name><meta-value>All relevant data are within the paper and its Supporting Information files.</meta-value></custom-meta></custom-meta-group></article-meta><notes><title>Data Availability</title><p>All relevant data are within the paper and its Supporting Information files.</p></notes></front><body><sec sec-type="intro" id="sec005"><title>Introduction</title><p>Snakebite poisoning is a significant cause of death and disability in rural West Africa [<xref rid="pntd.0004568.ref001" ref-type="bibr">1</xref>,<xref rid="pntd.0004568.ref002" ref-type="bibr">2</xref>,<xref rid="pntd.0004568.ref003" ref-type="bibr">3</xref>,<xref rid="pntd.0004568.ref004" ref-type="bibr">4</xref>,<xref rid="pntd.0004568.ref005" ref-type="bibr">5</xref>,<xref rid="pntd.0004568.ref006" ref-type="bibr">6</xref>,<xref rid="pntd.0004568.ref007" ref-type="bibr">7</xref>]. The exact burden of snakebite is difficult to ascertain and is often undereported. A study by Jean-Philippe Chippaux reported an estimate of over 314, 000 envenomations, 7300 mortality and nearly 6000 amputations occurring yearly in sub-Saharan Africa (SSA) [<xref rid="pntd.0004568.ref007" ref-type="bibr">7</xref>]. However, even in West Africa alone, a range of 1504 to 18,654 annual mortality from snakebite envenoming has been made [<xref rid="pntd.0004568.ref008" ref-type="bibr">8</xref>]. This is further compounded by the variability in snakebite incidence with estimates of as high as 500 bites per 100,000 persons per year in parts of northern Nigeria [<xref rid="pntd.0004568.ref009" ref-type="bibr">9</xref>].</p><p>Vipers (<italic>Echis ocellatus</italic>, <italic>E</italic>. <italic>leucogaster</italic> and <italic>E</italic>. <italic>jogeri)</italic> are a major cause of snakebite envenoming throughout the sub-region mainly in Benin republic, Burkina Faso, Cameroun, Chad, Gambia, Ghana, Mali, Niger, Nigeria, Togo and Senegal [<xref rid="pntd.0004568.ref001" ref-type="bibr">1</xref>,<xref rid="pntd.0004568.ref002" ref-type="bibr">2</xref>,<xref rid="pntd.0004568.ref003" ref-type="bibr">3</xref>,<xref rid="pntd.0004568.ref004" ref-type="bibr">4</xref>,<xref rid="pntd.0004568.ref005" ref-type="bibr">5</xref>,<xref rid="pntd.0004568.ref006" ref-type="bibr">6</xref>,<xref rid="pntd.0004568.ref007" ref-type="bibr">7</xref>]. In the sub-region, envenoming from snakes other than vipers mostly results from African spitting cobras (<italic>Naja nigricollis</italic>, <italic>N</italic>. <italic>katiensis</italic>), puff-adder (<italic>Bitis arietans</italic>), mambas (<italic>Dendroaspis viridis</italic>, <italic>D</italic>. <italic>polylepis</italic>), burrowing asps or stiletto snakes (<italic>Atractaspis</italic> species), night adders (<italic>Causus maculatus</italic>, <italic>C</italic>. <italic>rhombeatus</italic>, <italic>C</italic>. <italic>resimus</italic>, <italic>C</italic>. <italic>lichtensteinii</italic>) and very rarely boomslang (<italic>Dispholidus typus</italic>). Joger’s carpet viper (<italic>E</italic>. <italic>jogeri</italic>) is confined to Mali. Romane’s carpet viper (<italic>Echis leucogaster</italic>) and Egyptian cobras (<italic>Naja haje</italic> and <italic>N</italic>. <italic>senegalensis</italic>) are causes of snakebite envenoming in the Sahelian and drier parts of West Africa while the forest cobra (<italic>Naja melanoleuca</italic>) and the Gaboon viper (<italic>Bitis gabonica</italic>) cause occasional bites in the rain forest and South-eastern parts of the sub-region [<xref rid="pntd.0004568.ref001" ref-type="bibr">1</xref>,<xref rid="pntd.0004568.ref005" ref-type="bibr">5</xref>,<xref rid="pntd.0004568.ref007" ref-type="bibr">7</xref>].</p><p>In West Africa, carpet vipers may account for as many as two thirds of all snakebite envenoming although their range is limited to the savannah region [<xref rid="pntd.0004568.ref001" ref-type="bibr">1</xref>,<xref rid="pntd.0004568.ref009" ref-type="bibr">9</xref>,<xref rid="pntd.0004568.ref010" ref-type="bibr">10</xref>,<xref rid="pntd.0004568.ref011" ref-type="bibr">11</xref>]. Envenoming from carpet vipers leads to swelling and tissue damage at the site of bite, local and systematic bleeding, anaemia and shock. Often death results from cerebral haemorrhage, bleeding elsewhere or haemorrhagic shock [<xref rid="pntd.0004568.ref001" ref-type="bibr">1</xref>,<xref rid="pntd.0004568.ref010" ref-type="bibr">10</xref>,<xref rid="pntd.0004568.ref011" ref-type="bibr">11</xref>]. The bleeding abnormality results from a prothrombin activating metalloprotease “Ecarin” and a FX activating component, an anticoagulant, platelet activator/inhibitor and haemorrhagins in the snake’s venom [<xref rid="pntd.0004568.ref001" ref-type="bibr">1</xref>,<xref rid="pntd.0004568.ref010" ref-type="bibr">10</xref>,<xref rid="pntd.0004568.ref011" ref-type="bibr">11</xref>]. Non-clotting blood detected by the 20minute Whole Blood Clotting Test [20WBCT] virtually confirms carpet viper envenoming in the northern third of Africa (roughly north of the equator) and is utilized to assess adequacy of treatment [<xref rid="pntd.0004568.ref001" ref-type="bibr">1</xref>,<xref rid="pntd.0004568.ref010" ref-type="bibr">10</xref>,<xref rid="pntd.0004568.ref011" ref-type="bibr">11</xref>]. Most non-carpet viper bites lead to local swelling and tissue damage. The colubrids, boomslangs and twig snake (<italic>Thelotornis kirtlandii</italic>), are back fanged snakes that rarely envenom but can cause severe bleeding and acute kidney injury. Neurotoxic features may result from <italic>Naja haje</italic>, <italic>Naja melanoleuca</italic> and <italic>Dendroaspis</italic> spp bites with deaths often resulting from respiratory muscle paralysis [<xref rid="pntd.0004568.ref012" ref-type="bibr">12</xref>]. The risk of death from snakebites other than viper envenoming is lower [<xref rid="pntd.0004568.ref009" ref-type="bibr">9</xref>,<xref rid="pntd.0004568.ref013" ref-type="bibr">13</xref>,<xref rid="pntd.0004568.ref014" ref-type="bibr">14</xref>,<xref rid="pntd.0004568.ref015" ref-type="bibr">15</xref>,<xref rid="pntd.0004568.ref016" ref-type="bibr">16</xref>,<xref rid="pntd.0004568.ref017" ref-type="bibr">17</xref>], but cobra spits may lead to blindness and bites to cancerous ulcers, abortions, scarring, arthrodeses, contractures and psychological impairment leading to permanent disability and productivity loss following hospitalization and incapacitation [<xref rid="pntd.0004568.ref007" ref-type="bibr">7</xref>,<xref rid="pntd.0004568.ref018" ref-type="bibr">18</xref>,<xref rid="pntd.0004568.ref019" ref-type="bibr">19</xref>,<xref rid="pntd.0004568.ref020" ref-type="bibr">20</xref>,<xref rid="pntd.0004568.ref021" ref-type="bibr">21</xref>]. Cessation of bleeding abnormalities and restoration of clotting following administration of effective antivenom usually occurs promptly in carpet viper envenoming. Antivenom is efficacious in decreasing the likelihood of dying and is the main treatment for snakebite envenoming [<xref rid="pntd.0004568.ref001" ref-type="bibr">1</xref>,<xref rid="pntd.0004568.ref011" ref-type="bibr">11</xref>,<xref rid="pntd.0004568.ref022" ref-type="bibr">22</xref>,<xref rid="pntd.0004568.ref023" ref-type="bibr">23</xref>]. However, its administration is associated with early adverse reactions (EAR) which rarely results in fatality.[<xref rid="pntd.0004568.ref024" ref-type="bibr">24</xref>,<xref rid="pntd.0004568.ref025" ref-type="bibr">25</xref>,<xref rid="pntd.0004568.ref026" ref-type="bibr">26</xref>]. Specific interventions may be required to either prevent EAR with administration of premedication prior to antivenom or to treat it once developed following antivenom administration [<xref rid="pntd.0004568.ref025" ref-type="bibr">25</xref>,<xref rid="pntd.0004568.ref026" ref-type="bibr">26</xref>]. Antivenoms are formulated as either liquid agents that needs to conveyed and stored at low temperature with a life span of about three years [<xref rid="pntd.0004568.ref027" ref-type="bibr">27</xref>,<xref rid="pntd.0004568.ref028" ref-type="bibr">28</xref>] or as freeze dried substances that are more stable with extended shelf life. Both types of formulations have been produced for the sub-region [<xref rid="pntd.0004568.ref006" ref-type="bibr">6</xref>,<xref rid="pntd.0004568.ref027" ref-type="bibr">27</xref>,<xref rid="pntd.0004568.ref028" ref-type="bibr">28</xref>]. The average cost per treatment of antivenom was reported as US$124 (range US$55–$640) although a median price of US$153 was also reported for Sub-Saharan Africa [<xref rid="pntd.0004568.ref029" ref-type="bibr">29</xref>,<xref rid="pntd.0004568.ref030" ref-type="bibr">30</xref>,<xref rid="pntd.0004568.ref031" ref-type="bibr">31</xref>]. The few effective antivenoms in the sub-region generally have been scarce, locally unaffordable and inaccessible where they are most needed. Partly for these reasons antivenom utilization has drastically declined to a very small fraction of indicated need. The situation has been compounded further by the recent announcement by Sanofi-Pasteur that production and distribution of FAV Afrique, currently the most widely distributed and most dependable antivenom in the sub-region, will be discontinued by 2016. Its loss will exacerbate an already serious public health crisis and makes the management of snakebite even more challenging [<xref rid="pntd.0004568.ref032" ref-type="bibr">32</xref>]. It is therefore extremely important within the context of other competing public health priorities to assess the health economics of antivenoms to guide policy. Before the recent publication of our work focusing on Nigeria [<xref rid="pntd.0004568.ref033" ref-type="bibr">33</xref>], few economic evaluations of preliminary nature had been conducted on antivenoms [<xref rid="pntd.0004568.ref034" ref-type="bibr">34</xref>,<xref rid="pntd.0004568.ref035" ref-type="bibr">35</xref>]. Here, we evaluated the cost-effectiveness of antivenom utility in the treatment of snakebite envenomation by computing incremental cost effectiveness ratios (ICERs) of the cost per death averted and the cost per DALY averted by adapting a previously published model for Nigeria to 16 countries in WA. We performed the analysis from healthcare system perspective to provide policy makers with evidence towards broadening access to antivenoms given their importance in preventing loss of lives and limbs among poor vulnerable communities in West Africa.</p></sec><sec sec-type="materials|methods" id="sec006"><title>Materials and Methods</title><sec id="sec007"><title>Model Overview</title><p>A decision analytic model (<xref ref-type="fig" rid="pntd.0004568.g001">Fig 1</xref>) was adapted to estimate health outcomes and costs associated with the availability and use of geographically appropriate and effective antivenoms for snakebite poisoning in West Africa [<xref rid="pntd.0004568.ref033" ref-type="bibr">33</xref>]. Details of the model structure are described elsewhere [<xref rid="pntd.0004568.ref033" ref-type="bibr">33</xref>]. Briefly, the model assessed the availability of effective antivenoms relative to no availability in the decision node. The model differentiated snakebite envenoming by carpet viper and non-carpet viper and distinction was made on the basis of the 20WBCT in the treatment arm of the model. Evidence of coagulopathy would lead to the administration of mono-specific antivenom that neutralizes carpet viper venom only, whereas absence of coagulopathy triggers the administration of a polyspecific antivenom that neutralizes venoms from several snakes, including the carpet viper. In the first chance node, the model included EARs associated with antivenom use, which are more likely to occur with polyspecific rather than the monospecific antivenom [<xref rid="pntd.0004568.ref023" ref-type="bibr">23</xref>,<xref rid="pntd.0004568.ref027" ref-type="bibr">27</xref>,<xref rid="pntd.0004568.ref028" ref-type="bibr">28</xref>,<xref rid="pntd.0004568.ref036" ref-type="bibr">36</xref>,<xref rid="pntd.0004568.ref037" ref-type="bibr">37</xref>]. Symptoms of EAR were diverse and death could happen in about 1% of cases [<xref rid="pntd.0004568.ref024" ref-type="bibr">24</xref>,<xref rid="pntd.0004568.ref025" ref-type="bibr">25</xref>,<xref rid="pntd.0004568.ref026" ref-type="bibr">26</xref>]. Survivors of snakebite may recover completely or remain with significant sequaela (e.g. amputation) that was considered in the model. Treatment outcomes were converted into DALYs on the basis of local life expectancy. Tree Age Pro Suite Healthcare 2014 software was used for analyses.</p><fig id="pntd.0004568.g001" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pntd.0004568.g001</object-id><label>Fig 1</label><caption><title>Decision tree model for managing snakebite envenoming with or without FAV Afrique antivenom in Cameroun (each of the 16 countries has a similar model with its data input).</title><p>Model parameter definitions: c20WBCTest = cost of 20 minutes Whole Blood Clotting Test on 10 occassions over 7 days at diagnoses and monitoring; cAdvReaction = Cost of managing early adverse reactions; cAntivenom = Cost of Antivenom; cFeed_Transp = Cost of transporation and stay in Hospital for 7days; cRefrg_Transp = Cost of shipping and refrigeration; cNoAntivenom = Cost of management without effective antivenoms either traditional/herbal care or other alternatives; cSupp_care = Cost of supportive care. All costs are in US$. antivenomeff = Effectiveness of antivenom to prevent death; pEARmono = probability of early adverse reactionswith monospecific antivenom; pEARpoly = probability of early adverse reactionswith polyspecific antivenom; pEARmort = probability of dying following effective antivenom and early adverse reactions; pCVmort = probability of dying following carpet viper envenoming; pNCVmort = probability of dying following non-carpet viper envenoming; pCV = proportion of envenoming due to carpet viper; pDisabl = probability of disability; dw = disability weighting of consequences of snakebite envenoming; x = effect of adrenaline premedication reduction of risk of early adverse reactions.</p></caption><graphic xlink:href="pntd.0004568.g001"></graphic></fig></sec><sec id="sec008"><title>Model Inputs</title><sec id="sec009"><title>Antivenom effectiveness and Early Adverse Reactions (EAR) data</title><p>The likelihood of death from carpet viper and other snakebites among untreated victims was previously reported at 8.1–15.83% and 5–27.3% respectively [<xref rid="pntd.0004568.ref009" ref-type="bibr">9</xref>,<xref rid="pntd.0004568.ref010" ref-type="bibr">10</xref>,<xref rid="pntd.0004568.ref038" ref-type="bibr">38</xref>,<xref rid="pntd.0004568.ref039" ref-type="bibr">39</xref>,<xref rid="pntd.0004568.ref040" ref-type="bibr">40</xref>,<xref rid="pntd.0004568.ref041" ref-type="bibr">41</xref>,<xref rid="pntd.0004568.ref042" ref-type="bibr">42</xref>] although these were varied in sensitivity analyses. When data on antivenom effectiveness was available for a given country, it was applied for that country. It ranged from 56.43% to 92% against carpet viper deaths. A meta-analysis estimate was applied for countries without data (<xref ref-type="table" rid="pntd.0004568.t001">Table 1</xref>) [<xref rid="pntd.0004568.ref038" ref-type="bibr">38</xref>,<xref rid="pntd.0004568.ref039" ref-type="bibr">39</xref>,<xref rid="pntd.0004568.ref040" ref-type="bibr">40</xref>]. There hasn’t been placebo-controlled randomized controlled trials (RCT) ever conducted for antivenom assessment and the estimates of effectiveness derived from the meta-analysis that exclusively only included observational studies from Chad, Ghana and Nigeria [<xref rid="pntd.0004568.ref010" ref-type="bibr">10</xref>,<xref rid="pntd.0004568.ref022" ref-type="bibr">22</xref>,<xref rid="pntd.0004568.ref037" ref-type="bibr">37</xref>,<xref rid="pntd.0004568.ref038" ref-type="bibr">38</xref>,<xref rid="pntd.0004568.ref039" ref-type="bibr">39</xref>] were applied in the model. Results from the meta-analysis suggested that an effective antivenom has a 75% (95% confidence interval: 55–86%) effectiveness in averting mortality from carpet viper bites [<xref rid="pntd.0004568.ref022" ref-type="bibr">22</xref>]. Since the meta-analysis included studies wherein polyspecific antivenoms were used, these estimates of effectiveness were applied against non-carpet viper deaths except in Benin and Guinea-Conakry, where country-level effectiveness data exists for Antivipmyn antivenom against non-carpet viper (elapid) deaths, reported at 43.6% (0–80.5%) (<xref ref-type="table" rid="pntd.0004568.t001">Table 1</xref>) [<xref rid="pntd.0004568.ref042" ref-type="bibr">42</xref>]. However, in a scenario analysis antivenoms were assumed to be ineffective (0%) against non-carpet viper envenoming. Estimates of EAR for the corresponding antivenoms were Antivipmyn 3.3% and FAV Afrique 4.3% as obtained in observational studies while it was EchiTab-G 19% and EchiTab-Plus 26% [<xref rid="pntd.0004568.ref023" ref-type="bibr">23</xref>,<xref rid="pntd.0004568.ref036" ref-type="bibr">36</xref>,<xref rid="pntd.0004568.ref037" ref-type="bibr">37</xref>]. For countries where none of the antivenoms have been in use, the EAR risk median estimate of 4.3% was used in the model [<xref rid="pntd.0004568.ref036" ref-type="bibr">36</xref>]. The EAR estimates were varied from 0% to 30% in sensitivity analyses. The risk for disability (limb amputation) among survivors was approximated to 3% from studies in sub-Saharan Africa and the tropics [<xref rid="pntd.0004568.ref007" ref-type="bibr">7</xref>,<xref rid="pntd.0004568.ref043" ref-type="bibr">43</xref>,<xref rid="pntd.0004568.ref044" ref-type="bibr">44</xref>]. In base-case analysis antivenom administration had no effect on amputation, however, effectiveness was applied in sensitivity analyses. The mean ages of snakebite envenomed victims were reported for Chad 25.2 years, Niger 29 years, Nigeria 26 years and Mali 28 years [<xref rid="pntd.0004568.ref038" ref-type="bibr">38</xref>,<xref rid="pntd.0004568.ref039" ref-type="bibr">39</xref>,<xref rid="pntd.0004568.ref041" ref-type="bibr">41</xref>,<xref rid="pntd.0004568.ref045" ref-type="bibr">45</xref>,<xref rid="pntd.0004568.ref046" ref-type="bibr">46</xref>]. So, since snakebite envenoming occurs among persons with average age in the 25–29 year age group, we determined the remaining local life expectancies in this age group for the 16 countries ranged from 37 years in Sierra-Leone to 45 years in Ghana and Senegal (<xref ref-type="table" rid="pntd.0004568.t001">Table 1</xref>) [<xref rid="pntd.0004568.ref047" ref-type="bibr">47</xref>]. The base-case analysis on disability was restricted to extremity amputation although blindness from venom-ophthalmia and Post Traumatic Stress Disorder (PTSD) from encountering snake with respective disability weights of 0.552 and 0.105 [<xref rid="pntd.0004568.ref048" ref-type="bibr">48</xref>] were also explored in scenario analyses. An annual discount rate of 3% was applied on the health outcomes (mortality and amputation) and the associated amputation-related disability weight used was 0.102 [<xref rid="pntd.0004568.ref048" ref-type="bibr">48</xref>]. The model was adapted to 3 types of antivenoms used in WA: Antivipmyn in Benin and Guinea Conakry; EchiTab-G and EchiTab-Plus in Burkina Faso and Nigeria; FAV Afrique in Cameroun, Chad, Ghana and Mali. For the remaining 8 countries without evidence of effectiveness data for a particular antivenom, the meta-analytic estimates were used [<xref rid="pntd.0004568.ref022" ref-type="bibr">22</xref>]. Where other required data item was unavailable, data from adjacent or neighboring countries were used to input a model with mixed data sources. These parameters for the respective models were obtained in the literature and imputed to the antivenom-defined models and was run for each of the 16 countries.</p><table-wrap id="pntd.0004568.t001" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pntd.0004568.t001</object-id><label>Table 1</label><caption><title>Data estimates used in the model by country.</title></caption><alternatives><graphic id="pntd.0004568.t001g" xlink:href="pntd.0004568.t001"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="justify" rowspan="1" colspan="1"></th><th align="justify" rowspan="1" colspan="1">(a) Mean age at bite (+remaining life expectancy [2012]), years</th><th align="justify" rowspan="1" colspan="1">(b) Proportion of envenoming due to CV or vipers (%)</th><th align="justify" rowspan="1" colspan="1">(c) Untreated Mortality (CV; Non-CV)</th><th align="justify" rowspan="1" colspan="1">(d) Mortality post AV (CV; Non-CV)</th><th align="justify" rowspan="1" colspan="1">AV effectiveness against mortality (e) = [1-RR] or alternatively = (c-d)/c (for CV; Non-CV)</th><th align="justify" rowspan="1" colspan="1">Risk of Early Adverse Reactions with CV(mono) and NCV(poly[(%)</th><th align="justify" rowspan="1" colspan="1">Comments</th><th align="justify" rowspan="1" colspan="1">References</th></tr></thead><tbody><tr><td align="justify" colspan="9" rowspan="1">Model 1: Antivipmyn Antivenom</td></tr><tr><td align="justify" rowspan="1" colspan="1">Benin Republic</td><td align="justify" rowspan="1" colspan="1">25–29 (44)</td><td align="justify" rowspan="1" colspan="1">85%</td><td align="justify" rowspan="1" colspan="1">15%; 9/33(27.3%)</td><td align="justify" rowspan="1" colspan="1">3.11%; 4/26(15.4%)</td><td align="justify" rowspan="1" colspan="1">79.3%; (NA) 43.6% (0–80.5%)</td><td align="justify" rowspan="1" colspan="1">3.3%</td><td align="justify" rowspan="1" colspan="1">Used NCV data from Guinea</td><td align="justify" rowspan="1" colspan="1">Fayomi et al 2002 [<xref rid="pntd.0004568.ref004" ref-type="bibr">4</xref>]; Chippaux et al 2007 [<xref rid="pntd.0004568.ref006" ref-type="bibr">6</xref>]; Balde et al 2012 [<xref rid="pntd.0004568.ref037" ref-type="bibr">37</xref>]; Balde et al 2013 [<xref rid="pntd.0004568.ref042" ref-type="bibr">42</xref>];</td></tr><tr><td align="justify" rowspan="1" colspan="1">Guinea-Conakry</td><td align="justify" rowspan="1" colspan="1">25–29 (43)</td><td align="justify" rowspan="1" colspan="1">83%</td><td align="justify" rowspan="1" colspan="1">15%; 9/33(27.3%)</td><td align="justify" rowspan="1" colspan="1">3.11%; 4/26(15.4%)</td><td align="justify" rowspan="1" colspan="1">79.3%; (NA) 43.6% (0–80.5%)</td><td align="justify" rowspan="1" colspan="1">3.3%</td><td align="justify" rowspan="1" colspan="1">Used CV data from Benin</td><td align="justify" rowspan="1" colspan="1">Fayomi et al 2002 [<xref rid="pntd.0004568.ref004" ref-type="bibr">4</xref>]; Chippaux et al 2007 [<xref rid="pntd.0004568.ref006" ref-type="bibr">6</xref>]; Balde et al 2012 [<xref rid="pntd.0004568.ref037" ref-type="bibr">37</xref>]; Balde et al 2013 [<xref rid="pntd.0004568.ref042" ref-type="bibr">42</xref>]; Adehossi et al 2011 [<xref rid="pntd.0004568.ref045" ref-type="bibr">45</xref>];</td></tr><tr><td align="justify" colspan="9" rowspan="1">Model 2: EchiTab-G and EchiTab-Plus Antivenom</td></tr><tr><td align="justify" rowspan="1" colspan="1">Nigeria</td><td align="justify" rowspan="1" colspan="1">26 (41)</td><td align="justify" rowspan="1" colspan="1">66%</td><td align="justify" rowspan="1" colspan="1">19/120(15.83%); 5%</td><td align="justify" rowspan="1" colspan="1">78/6137(1.27%)</td><td align="justify" rowspan="1" colspan="1">92% (87–95%)</td><td align="justify" rowspan="1" colspan="1">ET-19%; ETPlus-26%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">Warrell et al 1977 [<xref rid="pntd.0004568.ref010" ref-type="bibr">10</xref>]; Abubakar et al 2010[<xref rid="pntd.0004568.ref023" ref-type="bibr">23</xref>]; Habib & Abubakar 2011 [<xref rid="pntd.0004568.ref038" ref-type="bibr">38</xref>]; Pugh et al 1980 [<xref rid="pntd.0004568.ref013" ref-type="bibr">13</xref>]</td></tr><tr><td align="justify" rowspan="1" colspan="1">Burkina Faso</td><td align="justify" rowspan="1" colspan="1">25–29 (43)</td><td align="justify" rowspan="1" colspan="1">85%</td><td align="justify" rowspan="1" colspan="1">12.1%; 5%</td><td align="justify" rowspan="1" colspan="1">NA</td><td align="justify" rowspan="1" colspan="1">92% (87–95%)</td><td align="justify" rowspan="1" colspan="1">ET-19%; ETPlus-26%</td><td align="justify" rowspan="1" colspan="1">Used AV effect from Nigeria; Ghana mortality</td><td align="justify" rowspan="1" colspan="1">Warrell et al 1977 [<xref rid="pntd.0004568.ref010" ref-type="bibr">10</xref>]; Abubakar et al 2010[<xref rid="pntd.0004568.ref023" ref-type="bibr">23</xref>]; Habib & Abubakar 2011 [<xref rid="pntd.0004568.ref038" ref-type="bibr">38</xref>]; Visser et al 2008 [<xref rid="pntd.0004568.ref040" ref-type="bibr">40</xref>]; Pugh et al 1980 [<xref rid="pntd.0004568.ref013" ref-type="bibr">13</xref>]</td></tr><tr><td align="justify" colspan="9" rowspan="1">Model 3: FAV Afrique Antivenom</td></tr><tr><td align="justify" rowspan="1" colspan="1">Cameroon</td><td align="justify" rowspan="1" colspan="1">25–29 (41)</td><td align="justify" rowspan="1" colspan="1">85%</td><td align="justify" rowspan="1" colspan="1">15/98(15.3%)</td><td align="justify" rowspan="1" colspan="1">NA</td><td align="justify" rowspan="1" colspan="1">85.2%(56.1–95%);</td><td align="justify" rowspan="1" colspan="1">4.3%</td><td align="justify" rowspan="1" colspan="1">Used (c) & (e) from Chad/Ghana</td><td align="justify" rowspan="1" colspan="1">Chippaux et al 1999 [<xref rid="pntd.0004568.ref036" ref-type="bibr">36</xref>]; Bregani et al 2006 [<xref rid="pntd.0004568.ref039" ref-type="bibr">39</xref>]; Visser et al 2008 [<xref rid="pntd.0004568.ref040" ref-type="bibr">40</xref>];</td></tr><tr><td align="justify" rowspan="1" colspan="1">Chad</td><td align="justify" rowspan="1" colspan="1">25.2 (38)</td><td align="justify" rowspan="1" colspan="1">85%</td><td align="justify" rowspan="1" colspan="1">15/98(15.3%)</td><td align="justify" rowspan="1" colspan="1">4/60(6.67%)</td><td align="justify" rowspan="1" colspan="1">56.43% (0–85.2%);</td><td align="justify" rowspan="1" colspan="1">4.3%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">Chippaux et al 1999 [<xref rid="pntd.0004568.ref036" ref-type="bibr">36</xref>]; Bregani et al 2006 [<xref rid="pntd.0004568.ref039" ref-type="bibr">39</xref>];</td></tr><tr><td align="justify" rowspan="1" colspan="1">Ghana</td><td align="justify" rowspan="1" colspan="1">25–29 (45)</td><td align="justify" rowspan="1" colspan="1">85%</td><td align="justify" rowspan="1" colspan="1">8/66(12.1%); -</td><td align="justify" rowspan="1" colspan="1">5/278(1.8%)</td><td align="justify" rowspan="1" colspan="1">85.2%(56.1–95%);</td><td align="justify" rowspan="1" colspan="1">4.3%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">Chippaux et al 1999 [<xref rid="pntd.0004568.ref036" ref-type="bibr">36</xref>]; Visser et al 2008 [<xref rid="pntd.0004568.ref040" ref-type="bibr">40</xref>];</td></tr><tr><td align="justify" rowspan="1" colspan="1">Mali</td><td align="justify" rowspan="1" colspan="1">28 (43)</td><td align="justify" rowspan="1" colspan="1">85%</td><td align="justify" rowspan="1" colspan="1">8.1%; 5%</td><td align="justify" rowspan="1" colspan="1">1.5%</td><td align="justify" rowspan="1" colspan="1">81.48% (NA)</td><td align="justify" rowspan="1" colspan="1">4.3%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">Chippaux et al 1999 [<xref rid="pntd.0004568.ref036" ref-type="bibr">36</xref>]; Drame et al 2012 [<xref rid="pntd.0004568.ref041" ref-type="bibr">41</xref>]</td></tr><tr><td align="justify" colspan="9" rowspan="1">Other/Multiple Antivenoms</td></tr><tr><td align="justify" rowspan="1" colspan="1">Cote d’Ivoire</td><td align="justify" rowspan="1" colspan="1">25–29 (39)</td><td align="justify" rowspan="1" colspan="1">83%</td><td align="justify" rowspan="1" colspan="1">12.1%;-</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">75%(55–86%)-</td><td align="justify" rowspan="1" colspan="1">4.3%</td><td align="justify" rowspan="1" colspan="1">AV efficacy from meta-analysis</td><td align="justify" rowspan="1" colspan="1">Habib & Warrell 2013 [<xref rid="pntd.0004568.ref022" ref-type="bibr">22</xref>]; Chippaux et al 1999 [<xref rid="pntd.0004568.ref036" ref-type="bibr">36</xref>]; Visser et al 2008 [<xref rid="pntd.0004568.ref040" ref-type="bibr">40</xref>];</td></tr><tr><td align="justify" rowspan="1" colspan="1">Gambia</td><td align="justify" rowspan="1" colspan="1">25–29 (44)</td><td align="justify" rowspan="1" colspan="1">40%</td><td align="justify" rowspan="1" colspan="1">14.3%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">75%(55–86%)</td><td align="justify" rowspan="1" colspan="1">4.3%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">Enwere et al 2000 [<xref rid="pntd.0004568.ref003" ref-type="bibr">3</xref>]; Habib & Warrell 2013 [<xref rid="pntd.0004568.ref022" ref-type="bibr">22</xref>]; Chippaux et al 1999 [<xref rid="pntd.0004568.ref036" ref-type="bibr">36</xref>];</td></tr><tr><td align="justify" rowspan="1" colspan="1">Guinea-Bissau</td><td align="justify" rowspan="1" colspan="1">25–29 (41)</td><td align="justify" rowspan="1" colspan="1">40%</td><td align="justify" rowspan="1" colspan="1">15%; 27.3%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">75%(55–86%); 43.6% (0–80.5%)</td><td align="justify" rowspan="1" colspan="1">4.3%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">Habib & Warrell 2013 [<xref rid="pntd.0004568.ref022" ref-type="bibr">22</xref>]; Balde et al 2013 [<xref rid="pntd.0004568.ref042" ref-type="bibr">42</xref>]; Adehossi et al 2011 [<xref rid="pntd.0004568.ref045" ref-type="bibr">45</xref>];</td></tr><tr><td align="justify" rowspan="1" colspan="1">Liberia</td><td align="justify" rowspan="1" colspan="1">25–29 (44)</td><td align="justify" rowspan="1" colspan="1">0% (*1%)</td><td align="justify" rowspan="1" colspan="1">0%(*15%);5%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">75%(55–86%)</td><td align="justify" rowspan="1" colspan="1">4.3%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">Pugh et al 1980 [<xref rid="pntd.0004568.ref013" ref-type="bibr">13</xref>] Habib & Warrell 2013 [<xref rid="pntd.0004568.ref022" ref-type="bibr">22</xref>];</td></tr><tr><td align="justify" rowspan="1" colspan="1">Niger</td><td align="justify" rowspan="1" colspan="1">29 (44)</td><td align="justify" rowspan="1" colspan="1">85%</td><td align="justify" rowspan="1" colspan="1">15%; 5%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">75%(55–86%)</td><td align="justify" rowspan="1" colspan="1">4.3%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">Habib & Warrell 2013 [<xref rid="pntd.0004568.ref022" ref-type="bibr">22</xref>]; Chippaux et al 1999 [<xref rid="pntd.0004568.ref036" ref-type="bibr">36</xref>]; Fayomi et al 2002 [<xref rid="pntd.0004568.ref004" ref-type="bibr">4</xref>]; Adehossi et al 2011 [<xref rid="pntd.0004568.ref045" ref-type="bibr">45</xref>];</td></tr><tr><td align="justify" rowspan="1" colspan="1">Senegal</td><td align="justify" rowspan="1" colspan="1">25–29 (45)</td><td align="justify" rowspan="1" colspan="1">40%</td><td align="justify" rowspan="1" colspan="1">15%;5%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">75%(55–86%)</td><td align="justify" rowspan="1" colspan="1">4.3%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">Trape et al 2002 [<xref rid="pntd.0004568.ref005" ref-type="bibr">5</xref>];Habib & Warrell 2013 [<xref rid="pntd.0004568.ref022" ref-type="bibr">22</xref>]; Chippaux et al 1999 [<xref rid="pntd.0004568.ref036" ref-type="bibr">36</xref>]; Adehossi et al 2011 [<xref rid="pntd.0004568.ref045" ref-type="bibr">45</xref>];</td></tr><tr><td align="justify" rowspan="1" colspan="1">Sierra-Leone</td><td align="justify" rowspan="1" colspan="1">25–29 (37)</td><td align="justify" rowspan="1" colspan="1">0% (*1%)</td><td align="justify" rowspan="1" colspan="1">0% (*15%);5%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">75%(55–86%)</td><td align="justify" rowspan="1" colspan="1">4.3%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">Pugh et al 1980 [<xref rid="pntd.0004568.ref013" ref-type="bibr">13</xref>] Habib & Warrell 2013 [<xref rid="pntd.0004568.ref022" ref-type="bibr">22</xref>];</td></tr><tr><td align="justify" rowspan="1" colspan="1">Togo</td><td align="justify" rowspan="1" colspan="1">25–29 (43)</td><td align="justify" rowspan="1" colspan="1">85%</td><td align="justify" rowspan="1" colspan="1">12.1%; 5%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">75%(55–86%)—</td><td align="justify" rowspan="1" colspan="1">4.3%</td><td align="justify" rowspan="1" colspan="1"></td><td align="justify" rowspan="1" colspan="1">Habib & Warrell 2013 [<xref rid="pntd.0004568.ref022" ref-type="bibr">22</xref>]; Visser et al 2008 [<xref rid="pntd.0004568.ref040" ref-type="bibr">40</xref>];</td></tr></tbody></table></alternatives><table-wrap-foot><fn id="t001fn001"><p>CV—carpet viper; RR—Relative Risk</p></fn></table-wrap-foot></table-wrap></sec><sec id="sec010"><title>Cost data</title><p>The cost of the full antivenom treatment regimen was modeled as US$153 [<xref rid="pntd.0004568.ref029" ref-type="bibr">29</xref>,<xref rid="pntd.0004568.ref030" ref-type="bibr">30</xref>,<xref rid="pntd.0004568.ref031" ref-type="bibr">31</xref>]. The cost of care, ten 20WBCT measurements in 7 days, transportation to-and-from hospital and feeding for 7 days, shipping and freezing of antivenom, management of EAR, supportive care (such as pain relief, blood transfusion, medications, fluid replacement and wound management) were obtained from series of envenomed patients admitted to Kaltungo General Hospital in Nigeria <xref ref-type="table" rid="pntd.0004568.t002">Table 2</xref> [<xref rid="pntd.0004568.ref033" ref-type="bibr">33</xref>]. All costs were expressed in US$. Given snakebite is a short term condition and costs occur during a brief period of time (2 to 10 days), costs were not discounted to adjust for time elapsed between expenditure and outcome during Incremental Cost Effectiveness Ratio (ICER) calculations [<xref rid="pntd.0004568.ref049" ref-type="bibr">49</xref>,<xref rid="pntd.0004568.ref050" ref-type="bibr">50</xref>]. As a conservative analysis the alternative of no antivenom therapy carried a cost of zero as no treatment, care, test and EAR management was provided. However, in a scenario analysis cost of $65.63 was added/incurred for the alternative of no antivenom therapy, comprising of supportive care $18.75, feeding and transportation $43.75, and for 20WBCT $3.125. The ICER was computed by dividing total cost by the difference in DALYs (e.g., cost/DALY averted) [<xref rid="pntd.0004568.ref049" ref-type="bibr">49</xref>,<xref rid="pntd.0004568.ref050" ref-type="bibr">50</xref>].</p><table-wrap id="pntd.0004568.t002" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pntd.0004568.t002</object-id><label>Table 2</label><caption><title>General assumptions used in Monte Carlo simulations.</title></caption><alternatives><graphic id="pntd.0004568.t002g" xlink:href="pntd.0004568.t002"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="left" rowspan="1" colspan="1">Assumption</th><th align="left" rowspan="1" colspan="1">Base Case Value (BCV)</th><th align="left" rowspan="1" colspan="1">Range of BCVs</th><th align="left" rowspan="1" colspan="1">Distribution</th><th align="left" rowspan="1" colspan="1">Reference</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Proportion of envenoming due to CV/ Non-Elapids (%)</td><td align="left" rowspan="1" colspan="1">Varies by country</td><td align="left" rowspan="1" colspan="1">1–85%</td><td align="left" rowspan="1" colspan="1">Beta</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref001" ref-type="bibr">1</xref>,<xref rid="pntd.0004568.ref005" ref-type="bibr">5</xref>,<xref rid="pntd.0004568.ref006" ref-type="bibr">6</xref>,<xref rid="pntd.0004568.ref007" ref-type="bibr">7</xref>,<xref rid="pntd.0004568.ref036" ref-type="bibr">36</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">Mortality due to untreated CV envenoming (%)</td><td align="left" rowspan="1" colspan="1">Varies by country</td><td align="left" rowspan="1" colspan="1">8.1–15.83%</td><td align="left" rowspan="1" colspan="1">Beta</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref003" ref-type="bibr">3</xref>,<xref rid="pntd.0004568.ref004" ref-type="bibr">4</xref>,<xref rid="pntd.0004568.ref010" ref-type="bibr">10</xref>,<xref rid="pntd.0004568.ref039" ref-type="bibr">39</xref>,<xref rid="pntd.0004568.ref040" ref-type="bibr">40</xref>,<xref rid="pntd.0004568.ref041" ref-type="bibr">41</xref>,<xref rid="pntd.0004568.ref045" ref-type="bibr">45</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">Mortality due to untreated Non-CV/Elapid envenoming (%)</td><td align="left" rowspan="1" colspan="1">Varies by country</td><td align="left" rowspan="1" colspan="1">5–27.3%</td><td align="left" rowspan="1" colspan="1">Beta</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref013" ref-type="bibr">13</xref>,<xref rid="pntd.0004568.ref014" ref-type="bibr">14</xref>,<xref rid="pntd.0004568.ref042" ref-type="bibr">42</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">AV effectiveness against CV mortality (%)</td><td align="left" rowspan="1" colspan="1">Varies by country</td><td align="left" rowspan="1" colspan="1">56.43–92%</td><td align="left" rowspan="1" colspan="1">Beta</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref004" ref-type="bibr">4</xref>,<xref rid="pntd.0004568.ref006" ref-type="bibr">6</xref>,<xref rid="pntd.0004568.ref010" ref-type="bibr">10</xref>,<xref rid="pntd.0004568.ref022" ref-type="bibr">22</xref>,<xref rid="pntd.0004568.ref038" ref-type="bibr">38</xref>,<xref rid="pntd.0004568.ref039" ref-type="bibr">39</xref>,<xref rid="pntd.0004568.ref040" ref-type="bibr">40</xref>,<xref rid="pntd.0004568.ref041" ref-type="bibr">41</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">AV effectiveness against Non-CV/Elapid mortality (%)</td><td align="left" rowspan="1" colspan="1">Varies by country</td><td align="left" rowspan="1" colspan="1">43.6–92%</td><td align="left" rowspan="1" colspan="1">Beta</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref010" ref-type="bibr">10</xref>,<xref rid="pntd.0004568.ref038" ref-type="bibr">38</xref>,<xref rid="pntd.0004568.ref042" ref-type="bibr">42</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">Risk of AV EAR for CV envenoming (%)</td><td align="left" rowspan="1" colspan="1">Varies by country</td><td align="left" rowspan="1" colspan="1">3.3–19%</td><td align="left" rowspan="1" colspan="1">Beta</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref023" ref-type="bibr">23</xref>,<xref rid="pntd.0004568.ref036" ref-type="bibr">36</xref>,<xref rid="pntd.0004568.ref037" ref-type="bibr">37</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">Risk of AV EAR for Non-CV envenoming (%)</td><td align="left" rowspan="1" colspan="1">Varies by country</td><td align="left" rowspan="1" colspan="1">3.3–26%</td><td align="left" rowspan="1" colspan="1">Beta</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref023" ref-type="bibr">23</xref>,<xref rid="pntd.0004568.ref036" ref-type="bibr">36</xref>,<xref rid="pntd.0004568.ref037" ref-type="bibr">37</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">Risk of AV EAR mortality (%)</td><td align="left" rowspan="1" colspan="1">1%</td><td align="left" rowspan="1" colspan="1">Same for each country</td><td align="left" rowspan="1" colspan="1">Beta</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref024" ref-type="bibr">24</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">Risk of amputation following envenoming (%)</td><td align="left" rowspan="1" colspan="1">3%</td><td align="left" rowspan="1" colspan="1">Same for each country</td><td align="left" rowspan="1" colspan="1">Beta</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref007" ref-type="bibr">7</xref>,<xref rid="pntd.0004568.ref043" ref-type="bibr">43</xref>,<xref rid="pntd.0004568.ref044" ref-type="bibr">44</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">Disability weight for amputation</td><td align="left" rowspan="1" colspan="1">0.102</td><td align="left" rowspan="1" colspan="1">Same for each country</td><td align="left" rowspan="1" colspan="1">Beta</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref048" ref-type="bibr">48</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">Cost of antivenom (US$)</td><td align="left" rowspan="1" colspan="1">$153</td><td align="left" rowspan="1" colspan="1">Same for each country</td><td align="left" rowspan="1" colspan="1">Normal</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref029" ref-type="bibr">29</xref>,<xref rid="pntd.0004568.ref030" ref-type="bibr">30</xref>,<xref rid="pntd.0004568.ref031" ref-type="bibr">31</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">Cost of 20min Whole Blood Clotting Test</td><td align="left" rowspan="1" colspan="1">$3.125</td><td align="left" rowspan="1" colspan="1">Same for each country</td><td align="left" rowspan="1" colspan="1">Normal</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref033" ref-type="bibr">33</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">Cost of managing Early Adverse Reactions</td><td align="left" rowspan="1" colspan="1">$1.875</td><td align="left" rowspan="1" colspan="1">Same for each country</td><td align="left" rowspan="1" colspan="1">Normal</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref033" ref-type="bibr">33</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">Cost of supportive care</td><td align="left" rowspan="1" colspan="1">$18.75</td><td align="left" rowspan="1" colspan="1">Same for each country</td><td align="left" rowspan="1" colspan="1">Normal</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref033" ref-type="bibr">33</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">Cost of feeding and transportation</td><td align="left" rowspan="1" colspan="1">$43.75</td><td align="left" rowspan="1" colspan="1">Same for each country</td><td align="left" rowspan="1" colspan="1">Normal</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref033" ref-type="bibr">33</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">Cost of refrigeration and transportation</td><td align="left" rowspan="1" colspan="1">$18.75</td><td align="left" rowspan="1" colspan="1">Same for each country</td><td align="left" rowspan="1" colspan="1">Normal</td><td align="left" rowspan="1" colspan="1"><xref rid="pntd.0004568.ref033" ref-type="bibr">33</xref></td></tr><tr><td align="left" rowspan="1" colspan="1">Cost of no antivenom (US$)</td><td align="left" rowspan="1" colspan="1">$0</td><td align="left" rowspan="1" colspan="1">Same for each country</td><td align="left" rowspan="1" colspan="1">Not varied</td><td align="left" rowspan="1" colspan="1">Our assumption</td></tr><tr><td align="left" rowspan="1" colspan="1">DALYs averted per death averted (3% discounted)</td><td align="left" rowspan="1" colspan="1">Varies by country</td><td align="left" rowspan="1" colspan="1">22.17–24.52</td><td align="left" rowspan="1" colspan="1">Not varied</td><td align="left" rowspan="1" colspan="1">Our calculations</td></tr><tr><td align="left" rowspan="1" colspan="1">DALYs averted per amputation averted (3% discounted)</td><td align="left" rowspan="1" colspan="1">Varies by country</td><td align="left" rowspan="1" colspan="1">2.26–2.50</td><td align="left" rowspan="1" colspan="1">Not varied</td><td align="left" rowspan="1" colspan="1">Our calculations</td></tr></tbody></table></alternatives></table-wrap></sec><sec id="sec011"><title>Sensitivity analysis</title><p>One-way sensitivity analysis was performed for select input variables to test robustness and determine the most important variables influencing cost-effectiveness of an antivenom programme. Each base-case model input was varied independently according to the upper and lower limits obtained from literature and according to low and high value scenarios.</p><p>In addition, Probablistic Sensitivity Analyses (PSA) were performed using Monte Carlo simulation by running 10,000 iterations of the model while randomly selecting the values for 16 key model inputs from a probability distribution that was defined for each of the parameters (<xref ref-type="table" rid="pntd.0004568.t002">Table 2</xref>). This process enabled us to estimate the 95% confidence interval around the base case ICER estimates for each of the 16 countries included in the analysis, and it also allowed us to estimate the probability that antivenom therapy is cost-effective by calculating the proportion of 10,000 iterations that resulted in ICERs that fell below commonly accepted cost-effectiveness thresholds of one time per capita Gross Domestic Product (GDP) for each of the 16 countries [<xref rid="pntd.0004568.ref051" ref-type="bibr">51</xref>,<xref rid="pntd.0004568.ref052" ref-type="bibr">52</xref>].</p><p>The study reporting was done consistent to standard guidelines for cost effectiveness analyses and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement [<xref rid="pntd.0004568.ref049" ref-type="bibr">49</xref>,<xref rid="pntd.0004568.ref050" ref-type="bibr">50</xref>,<xref rid="pntd.0004568.ref052" ref-type="bibr">52</xref>,<xref rid="pntd.0004568.ref053" ref-type="bibr">53</xref>,<xref rid="pntd.0004568.ref054" ref-type="bibr">54</xref>].</p></sec></sec></sec><sec sec-type="results" id="sec012"><title>Results</title><p>The cost/death averted for the 16 countries of interest varied. It was as low as $1,997 in Guinea Bissau to as high as $6,205 in Liberia and Sierra Leone. The cost/DALY averted ranged from a low of $83 (95% Confidence Interval: $36-$240) for Benin Republic to a high of $281 ($159–457) for Sierra-Leone. In all cases, the base-case cost/DALY averted estimate fell below the commonly accepted threshold of one time per capita GDP, suggesting that AV is highly cost-effective for the treatment of snakebite in all 16 WA countries [<xref rid="pntd.0004568.ref051" ref-type="bibr">51</xref>,<xref rid="pntd.0004568.ref052" ref-type="bibr">52</xref>].</p><p>The findings from the analyses were also consistent to variations of inputs in 1-way sensitivity and scenario analyses as depicted (<xref ref-type="table" rid="pntd.0004568.t003">Table 3</xref> and <xref ref-type="fig" rid="pntd.0004568.g002">Fig 2</xref>). The individual countries’ model results were most sensitive to effectiveness of antivenom in decreasing mortality, natural (unattended) mortality, costs of antivenoms and types of snake causing envenoming (<xref ref-type="fig" rid="pntd.0004568.g002">Fig 2</xref>). Results were not sensitive to antivenom associated EAR or the cost of managing it. Varying the cost of antivenom from $125 to two times for victims who may require two doses, i.e. $306, still yielded ICER estimates that remain cost-effective. The ICERs rose when the frequency of snakebite envenomation due to saw-scaled viper was reduced to 0% except in Benin and Guinea Conakry where Antivipmyn antivenom is used and is effective even against elapids (<xref ref-type="table" rid="pntd.0004568.t003">Table 3</xref>) [<xref rid="pntd.0004568.ref042" ref-type="bibr">42</xref>].</p><fig id="pntd.0004568.g002" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pntd.0004568.g002</object-id><label>Fig 2</label><caption><title>Tornado diagrams assessing the impact of changes in envenoming/antivenom and cost parameters on the incremental cost-effectiveness ratio (ICER) per DALY for antivenom use in Guinea Bissau (L) and Senegal (R).</title><p>Diagram parameter definitions: c20WBCTest = cost of 20 minutes Whole Blood Clotting Test on 10 occassions over 7 days at diagnoses and monitoring; cAntivenom = Cost of Antivenom; cFeed_Transp = Cost of transporation and stay in Hospital for 7days; cRefrg_Transp = Cost of shipping and refrigeration; cNoAntivenom = Cost of management without effective antivenoms either traditional/herbal care or other alternatives; cSupp_care = Cost of supportive care. All costs are in US$. Antivenomeff = Effectiveness of antivenom to prevent death; pEARmono = probability of early adverse reactions with monospecific antivenom; pEARpoly = probability of early adverse reactionswith polyspecific antivenom; pEARmort = probability of dying following effective antivenom and early adverse reactions; pCVmort = probability of dying following carpet viper envenoming; pNCVmort = probability of dying following non-carpet viper envenoming; pCV = proportion of envenoming due to carpet viper; pDisabl = probability of disability.</p></caption><graphic xlink:href="pntd.0004568.g002"></graphic></fig><table-wrap id="pntd.0004568.t003" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pntd.0004568.t003</object-id><label>Table 3</label><caption><title>Results from model outputs by country and scenarios.</title></caption><alternatives><graphic id="pntd.0004568.t003g" xlink:href="pntd.0004568.t003"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="justify" rowspan="1" colspan="1">Country and GDP/Capita ($) [<xref rid="pntd.0004568.ref049" ref-type="bibr">49</xref>]</th><th align="justify" rowspan="1" colspan="1">Increm Cost Effect Ratio[ICER]/DALY ($) (95% Conf. Interval)</th><th align="justify" rowspan="1" colspan="1">Cost/Death Averted ($)</th><th align="justify" rowspan="1" colspan="1">Probability Antivenom is cost-effective (%)</th><th align="justify" rowspan="1" colspan="1">ICER if Antivenom Cost = $125</th><th align="justify" rowspan="1" colspan="1">ICER if Antivenom Cost = $306</th><th align="justify" rowspan="1" colspan="1">ICER if proportion of Carpet Viper = 0% ($)</th><th align="justify" rowspan="1" colspan="1">ICER if Av Effect for Non Carpet Viper = 0% ($)</th><th align="justify" rowspan="1" colspan="1">ICER if the ‘No Antivenom’ arm paid for Basic costs of $65.63<xref ref-type="table-fn" rid="t003fn001">*</xref></th></tr></thead><tbody><tr><td align="justify" rowspan="1" colspan="1">Benin (751)</td><td align="justify" rowspan="1" colspan="1">82.63 (36.41–240.09)</td><td align="char" char="." rowspan="1" colspan="1">1997.91</td><td align="char" char="." rowspan="1" colspan="1">99.99</td><td align="char" char="." rowspan="1" colspan="1">72.87</td><td align="char" char="." rowspan="1" colspan="1">135.96</td><td align="char" char="." rowspan="1" colspan="1">81.75</td><td align="char" char="." rowspan="1" colspan="1">97.26</td><td align="char" char="." rowspan="1" colspan="1">59.75</td></tr><tr><td align="justify" rowspan="1" colspan="1">B/Faso (652)</td><td align="justify" rowspan="1" colspan="1">99.44 (40.39–377.40)</td><td align="char" char="." rowspan="1" colspan="1">2384.81</td><td align="char" char="." rowspan="1" colspan="1">99.61</td><td align="char" char="." rowspan="1" colspan="1">87.98</td><td align="char" char="." rowspan="1" colspan="1">164.05</td><td align="char" char="." rowspan="1" colspan="1">226.53</td><td align="char" char="." rowspan="1" colspan="1">107.18</td><td align="char" char="." rowspan="1" colspan="1">71.94</td></tr><tr><td align="justify" rowspan="1" colspan="1">Cameroun (1220)</td><td align="justify" rowspan="1" colspan="1">86.97 (38.47–240.43)</td><td align="char" char="." rowspan="1" colspan="1">2030.05</td><td align="char" char="." rowspan="1" colspan="1">100.00</td><td align="char" char="." rowspan="1" colspan="1">76.70</td><td align="char" char="." rowspan="1" colspan="1">143.11</td><td align="char" char="." rowspan="1" colspan="1">238.39</td><td align="char" char="." rowspan="1" colspan="1">92.01</td><td align="char" char="." rowspan="1" colspan="1">62.89</td></tr><tr><td align="justify" rowspan="1" colspan="1">Chad (1035)</td><td align="justify" rowspan="1" colspan="1">136.94 (51.33–704.75)</td><td align="char" char="." rowspan="1" colspan="1">3070.80</td><td align="char" char="." rowspan="1" colspan="1">99.13</td><td align="char" char="." rowspan="1" colspan="1">120.77</td><td align="char" char="." rowspan="1" colspan="1">225.34</td><td align="char" char="." rowspan="1" colspan="1">376.61</td><td align="char" char="." rowspan="1" colspan="1">144.89</td><td align="char" char="." rowspan="1" colspan="1">99.03</td></tr><tr><td align="justify" rowspan="1" colspan="1">Cote d’Ivoire (1366)</td><td align="justify" rowspan="1" colspan="1">128.24 (51.20–461.64)</td><td align="char" char="." rowspan="1" colspan="1">2916.02</td><td align="char" char="." rowspan="1" colspan="1">99.97</td><td align="char" char="." rowspan="1" colspan="1">113.09</td><td align="char" char="." rowspan="1" colspan="1">211.04</td><td align="char" char="." rowspan="1" colspan="1">278.37</td><td align="char" char="." rowspan="1" colspan="1">139.16</td><td align="char" char="." rowspan="1" colspan="1">92.73</td></tr><tr><td align="justify" rowspan="1" colspan="1">Gambia (509)</td><td align="justify" rowspan="1" colspan="1">150.08 (72.18–305.49)</td><td align="char" char="." rowspan="1" colspan="1">3628.88</td><td align="char" char="." rowspan="1" colspan="1">99.99</td><td align="char" char="." rowspan="1" colspan="1">132.25</td><td align="char" char="." rowspan="1" colspan="1">247.47</td><td align="char" char="." rowspan="1" colspan="1">261.77</td><td align="char" char="." rowspan="1" colspan="1">229.59</td><td align="char" char="." rowspan="1" colspan="1">108.30</td></tr><tr><td align="justify" rowspan="1" colspan="1">Ghana (1646)</td><td align="justify" rowspan="1" colspan="1">103.61 (42.04–372.87)</td><td align="char" char="." rowspan="1" colspan="1">2532.73</td><td align="char" char="." rowspan="1" colspan="1">99.99</td><td align="char" char="." rowspan="1" colspan="1">91.38</td><td align="char" char="." rowspan="1" colspan="1">170.50</td><td align="char" char="." rowspan="1" colspan="1">227.63</td><td align="char" char="." rowspan="1" colspan="1">111.21</td><td align="char" char="." rowspan="1" colspan="1">74.93</td></tr><tr><td align="justify" rowspan="1" colspan="1">Guinea Bissau (576)</td><td align="justify" rowspan="1" colspan="1">87.09 (44.96–171.55)</td><td align="char" char="." rowspan="1" colspan="1">2032.72</td><td align="char" char="." rowspan="1" colspan="1">100.00</td><td align="char" char="." rowspan="1" colspan="1">76.75</td><td align="char" char="." rowspan="1" colspan="1">143.60</td><td align="char" char="." rowspan="1" colspan="1">84.76</td><td align="char" char="." rowspan="1" colspan="1">226.64</td><td align="char" char="." rowspan="1" colspan="1">62.85</td></tr><tr><td align="justify" rowspan="1" colspan="1">Guinea Conakry (493)</td><td align="justify" rowspan="1" colspan="1">83.54 (36.59–236.35)</td><td align="char" char="." rowspan="1" colspan="1">1997.41</td><td align="char" char="." rowspan="1" colspan="1">99.98</td><td align="char" char="." rowspan="1" colspan="1">73.67</td><td align="char" char="." rowspan="1" colspan="1">137.49</td><td align="char" char="." rowspan="1" colspan="1">82.68</td><td align="char" char="." rowspan="1" colspan="1">100.72</td><td align="char" char="." rowspan="1" colspan="1">60.40</td></tr><tr><td align="justify" rowspan="1" colspan="1">Liberia (414)</td><td align="justify" rowspan="1" colspan="1">256.61 (147.67–417.68)</td><td align="char" char="." rowspan="1" colspan="1">6204.95</td><td align="char" char="." rowspan="1" colspan="1">97.28</td><td align="char" char="." rowspan="1" colspan="1">226.00</td><td align="char" char="." rowspan="1" colspan="1">423.92</td><td align="char" char="." rowspan="1" colspan="1">261.77</td><td align="char" char="." rowspan="1" colspan="1">13,964.26</td><td align="char" char="." rowspan="1" colspan="1">184.85</td></tr><tr><td align="justify" rowspan="1" colspan="1">Mali (696)</td><td align="justify" rowspan="1" colspan="1">160.48 (82.21–306.83)</td><td align="char" char="." rowspan="1" colspan="1">3836.74</td><td align="char" char="." rowspan="1" colspan="1">100.00</td><td align="char" char="." rowspan="1" colspan="1">141.52</td><td align="char" char="." rowspan="1" colspan="1">264.06</td><td align="char" char="." rowspan="1" colspan="1">243.47</td><td align="char" char="." rowspan="1" colspan="1">178.09</td><td align="char" char="." rowspan="1" colspan="1">116.04</td></tr><tr><td align="justify" rowspan="1" colspan="1">Niger (385)</td><td align="justify" rowspan="1" colspan="1">97.23 (39.84–328.02)</td><td align="char" char="." rowspan="1" colspan="1">2351.06</td><td align="char" char="." rowspan="1" colspan="1">98.64</td><td align="char" char="." rowspan="1" colspan="1">85.75</td><td align="char" char="." rowspan="1" colspan="1">159.99</td><td align="char" char="." rowspan="1" colspan="1">261.77</td><td align="char" char="." rowspan="1" colspan="1">102.98</td><td align="char" char="." rowspan="1" colspan="1">70.31</td></tr><tr><td align="justify" rowspan="1" colspan="1">Nigeria (2742)</td><td align="justify" rowspan="1" colspan="1">92.56 (40.27–242.63)</td><td align="char" char="." rowspan="1" colspan="1">2160.33</td><td align="char" char="." rowspan="1" colspan="1">100.00</td><td align="char" char="." rowspan="1" colspan="1">81.61</td><td align="char" char="." rowspan="1" colspan="1">152.35</td><td align="char" char="." rowspan="1" colspan="1">232.04</td><td align="char" char="." rowspan="1" colspan="1">107.96</td><td align="char" char="." rowspan="1" colspan="1">66.91</td></tr><tr><td align="justify" rowspan="1" colspan="1">Senegal (1023)</td><td align="justify" rowspan="1" colspan="1">143.81 (67.34–317.76)</td><td align="char" char="." rowspan="1" colspan="1">3515.25</td><td align="char" char="." rowspan="1" colspan="1">100.00</td><td align="char" char="." rowspan="1" colspan="1">126.73</td><td align="char" char="." rowspan="1" colspan="1">237.14</td><td align="char" char="." rowspan="1" colspan="1">258.95</td><td align="char" char="." rowspan="1" colspan="1">216.41</td><td align="char" char="." rowspan="1" colspan="1">103.78</td></tr><tr><td align="justify" rowspan="1" colspan="1">Sierra Leone (590)</td><td align="justify" rowspan="1" colspan="1">280.77 (158.51–456.68)</td><td align="char" char="." rowspan="1" colspan="1">6204.95</td><td align="char" char="." rowspan="1" colspan="1">99.86</td><td align="char" char="." rowspan="1" colspan="1">247.27</td><td align="char" char="." rowspan="1" colspan="1">463.83</td><td align="char" char="." rowspan="1" colspan="1">286.42</td><td align="char" char="." rowspan="1" colspan="1">15,278.99</td><td align="char" char="." rowspan="1" colspan="1">202.25</td></tr><tr><td align="justify" rowspan="1" colspan="1">Togo (589)</td><td align="justify" rowspan="1" colspan="1">120.42 (47.62–455.04)</td><td align="char" char="." rowspan="1" colspan="1">2878.98</td><td align="char" char="." rowspan="1" colspan="1">98.86</td><td align="char" char="." rowspan="1" colspan="1">106.19</td><td align="char" char="." rowspan="1" colspan="1">198.14</td><td align="char" char="." rowspan="1" colspan="1">264.75</td><td align="char" char="." rowspan="1" colspan="1">129.25</td><td align="char" char="." rowspan="1" colspan="1">87.08</td></tr></tbody></table></alternatives><table-wrap-foot><fn id="t003fn001"><p>*Scenario of Basic costs in the No antivenom arm = Cost of supportive care ($18.75) + Cost of feeding and transportation ($43.75) + Cost of 20min Whole Blood Clotting Test ($3.125) = $65.63</p></fn><fn id="t003fn002"><p>AV—antivenom; ICER—Incremental Cost Effectiveness Ratio;</p></fn></table-wrap-foot></table-wrap><p>Moreover, the ICER ranged from $97.26 in Benin to high levels of $13,964.26 in Liberia and $15,278.99 in Sierra Leone even in the worst case scenario where (poly-specific) antivenoms have nil effectiveness (0%) against bites from snakes other than carpet viper. These estimates fall outside the cost-effectiveness thresholds in Liberia and Sierra Leone largely because non-carpet viper accounts for 99% of SBE. Applying a modest reduction of 40% on the probability of EAR with the use of adrenaline premedication [<xref rid="pntd.0004568.ref025" ref-type="bibr">25</xref>,<xref rid="pntd.0004568.ref026" ref-type="bibr">26</xref>,<xref rid="pntd.0004568.ref033" ref-type="bibr">33</xref>] gave a cost per DALY averted slightly lower than base-case ICERs. Similarly, the ICERs were only very slightly altered even when more serious or more frequent disabilities were substituted in the model. This was demonstrated with venom-induced-blindness (0.01%) or Post-Traumatic-Stress-Disorder (20%) with disability-weights of 0.552 and 0.105 respectively [<xref rid="pntd.0004568.ref018" ref-type="bibr">18</xref>,<xref rid="pntd.0004568.ref021" ref-type="bibr">21</xref>,<xref rid="pntd.0004568.ref048" ref-type="bibr">48</xref>].</p><p>Furthermore, our PSA confirms the model findings remain consistent to concurrent variation of all model inputs, as the ICERs with their respective 95% confidence limits are far less than the cost-effectiveness thresholds (<xref ref-type="table" rid="pntd.0004568.t003">Table 3</xref>). It showed that in majority of simulations (97.3% in Liberia to 100% in Cameroun, Guinea Bissau, Mali, Nigeria and Senegal (<xref ref-type="fig" rid="pntd.0004568.g003">Fig 3</xref>)) our model results yielded an ICER that fell below the threshold of one time per capita GDP, thus, indicating a high degree of confidence in our results [<xref rid="pntd.0004568.ref051" ref-type="bibr">51</xref>,<xref rid="pntd.0004568.ref052" ref-type="bibr">52</xref>].</p><fig id="pntd.0004568.g003" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pntd.0004568.g003</object-id><label>Fig 3</label><caption><title>Monte Carlo Simulation showing the probability antivenom is cost-effective in majority of iterations (out of 10,000) for 4 countries with respective Willingness To Pay (GDP/capita) and probabilities: top panel Chad (WTP $1035; prob-99.13%) [L] and Liberia (WTP $414; prob-97.28%) [R] and bottom panel Niger (WTP $385; prob-98.64%) [L] and Togo (WTP $589; prob-98.86%) [R].</title></caption><graphic xlink:href="pntd.0004568.g003"></graphic></fig></sec><sec sec-type="conclusions" id="sec013"><title>Discussion</title><p>Economic modeling is very useful in determining the best ways to utilize resources to optimally manage medical conditions where there are competing priorities and limited resources [<xref rid="pntd.0004568.ref049" ref-type="bibr">49</xref>]. This is the first extensive assessment of the cost-effectiveness of expanding antivenom access in the 16 countries in West Africa. We find that the cost/death averted for the 16 countries of interest ranged from $1,997 in Guinea Bissau to $6,205 for Liberia and Sierra Leone. The cost/DALY averted ranged from $83 (95% Confidence Interval: $36-$240) for Benin Republic to $281 ($159–457) for Sierra-Leone. The ICER point estimate is <$100/DALY averted in 7 countries, $100-$200/DALY averted in 7 countries and <$300/DALY averted in 2 countries. The results show that snakebite antivenoms are highly cost-effective in West Africa, as our findings are far less than the one time per capita GDP threshold [<xref rid="pntd.0004568.ref051" ref-type="bibr">51</xref>,<xref rid="pntd.0004568.ref052" ref-type="bibr">52</xref>]. While it will be worthwhile to repeat the analysis for similar geographic and socioeconomic settings, most of the model inputs such as the antivenom efficacy and cost would largely be similar across many African countries with similar GDPs where snakebite envenoming occurs. An exception may be the prevalence of carpet viper (<italic>Echis ocellatus</italic>) envenoming, a snake that is confined to West Africa extending eastwards only as far as Chad and Central Africa Republic. However, even in areas without carpet viper bites (0%) our results demonstrate that antivenoms remain highly cost-effective.</p><p>The combination of effective and relatively inexpensive antivenoms and the utilization of a cheap, dependable and simple point-of-care test have been instrumental to our results. Antivenom effectiveness is loosely inversely related to the ICER per DALY saved (<xref ref-type="fig" rid="pntd.0004568.g002">Fig 2</xref>) [<xref rid="pntd.0004568.ref033" ref-type="bibr">33</xref>]. With discontinuation of production of geographically appropriate effective antivenoms and marketing of inappropriate ineffective products the cost per DALY saved will substantially soar [<xref rid="pntd.0004568.ref032" ref-type="bibr">32</xref>,<xref rid="pntd.0004568.ref039" ref-type="bibr">39</xref>,<xref rid="pntd.0004568.ref040" ref-type="bibr">40</xref>]. The 20WBCT is discriminatory and will be useful following envenoming from other snakes in the rest of Africa that result in coagulopathy e.g., other species of carpet viper (<italic>Echis leucogaster</italic>, <italic>Echis pyramidum</italic>, <italic>Echis jogeri</italic>, <italic>Echis coloratus</italic>) and boomslang. In the context of differing circumstances where multiple types of snakes with varying manifestations of envenoming or lack of reliable cheap differentiating test, antivenoms may not be as cost-effective. Nevertheless, where patients come along with the dead snakes, decision on antivenom choice is feasible [<xref rid="pntd.0004568.ref023" ref-type="bibr">23</xref>] and in such cases the differentiating test becomes not so useful. In the face of competing health needs and constrained-resources, it would be helpful to contextualize our findings in the light of other healthcare initiatives. The cost-effectiveness of Human Immunodeficiency Virus treatment used in similar resource-constrained settings as first-line, second-line or for protecting negative partners among discordant partners ranged from US$530 to US$1037 per year of life gained [<xref rid="pntd.0004568.ref033" ref-type="bibr">33</xref>,<xref rid="pntd.0004568.ref055" ref-type="bibr">55</xref>,<xref rid="pntd.0004568.ref056" ref-type="bibr">56</xref>,<xref rid="pntd.0004568.ref057" ref-type="bibr">57</xref>]. However, these estimates are still higher than the highest ICERs obtained for two countries in this analysis, i.e., Liberia and Sierra-Leone with $257/DALY averted and $281/DALY averted respectively. The antivenom cost effectiveness is comparable to what obtains in other healthcare programmes. For example, the cost/DALY averted obtained in this study ranged from $100 to $200 for 7 countries (see <xref ref-type="table" rid="pntd.0004568.t003">Table 3</xref>) and is comparable to the cost effectiveness of rotavirus vaccines in other developing countries in Africa and Asia [<xref rid="pntd.0004568.ref033" ref-type="bibr">33</xref>,<xref rid="pntd.0004568.ref058" ref-type="bibr">58</xref>,<xref rid="pntd.0004568.ref059" ref-type="bibr">59</xref>]. Similarly, the cost/DALY averted in the remaining 7 countries was <$100/DALY averted and is similar to what obtains for preventing Human Papilloma Virus and pneumococcal infections with vaccines in West Africa [<xref rid="pntd.0004568.ref033" ref-type="bibr">33</xref>,<xref rid="pntd.0004568.ref060" ref-type="bibr">60</xref>,<xref rid="pntd.0004568.ref061" ref-type="bibr">61</xref>].</p><p>We estimated a cost/DALY averted ranging from $73 in Benin to $247 in Sierra Leone if the cost input of antivenom is reduced to $125 per dose as obtained in Mali [<xref rid="pntd.0004568.ref030" ref-type="bibr">30</xref>]. Doubling the cost of antivenom for patients requiring more than a dose still yielded ICERs that remain cost effective ranging from $136/DALY averted in Benin to $464/DALY averted in Sierra Leone.</p><p>In 8 of the 16 countries with neither indigenous antivenom effectiveness data nor data from adjacent countries, we used efficacy derived from a meta-analysis with data inputs from other countries in the sub-region [<xref rid="pntd.0004568.ref022" ref-type="bibr">22</xref>, <xref rid="pntd.0004568.ref038" ref-type="bibr">38</xref>].</p><p>The study has a number of limitations. First, the effectiveness of antivenom was derived from observational studies rather than RCTs. Definitive placebo controlled trials of antivenom are considered unethical and RCTs are unlikely to be conducted in the absence of a suitable comparator to antivenom. However, to reduce bias, improve data quality and validity of estimates, three investigators independently searched both English and French literature and extracted data using a checklist for consistency. Secondly, we applied the estimated protection conferred by antivenoms against carpet viper envenoming to the antivenoms used for other than carpet viper envenoming (except in Benin and Guinea Conakry with specific estimates), though this assumption was subsequently dropped in a scenario analysis where antivenoms were assumed to be ineffective (0%) against non-carpet viper envenoming. Thirdly, the analysis mainly considered amputation as the major disability to the exclusion of other anecdotal complications [<xref rid="pntd.0004568.ref007" ref-type="bibr">7</xref>, <xref rid="pntd.0004568.ref020" ref-type="bibr">20</xref>, <xref rid="pntd.0004568.ref043" ref-type="bibr">43</xref>, <xref rid="pntd.0004568.ref044" ref-type="bibr">44</xref>]. Fourthly, in our model, antivenoms only conferred protection against death—being a more objective and valid outcome. Fifthly, other benefits of antivenom (e.g. speedier recovery) were not included in the model. Sixth, we used separate EAR risk inputs for EchiTab-G and EchiTab-Plus respectively [<xref rid="pntd.0004568.ref023" ref-type="bibr">23</xref>] but could not discern their respective efficacy against mortality so the combined estimate of the two was used in Burkina Faso and Nigeria. Lastly, we did not include the costs incurred for logistics in conveying and preserving antivenoms as we assumed facilities for existing health programmes will be utilized.</p><sec id="sec014"><title>Conclusion</title><p>The findings from the cost effectiveness analysis demonstrate that providing and broadening antivenom access throughout areas at risk in rural West Africa should be prioritized given the considerable reduction in deaths and disabilities that could be derived at a relatively small cost.</p></sec></sec></body><back><ref-list><title>References</title><ref id="pntd.0004568.ref001"><label>1</label><mixed-citation publication-type="journal"><name><surname>Warrell</surname><given-names>DA</given-names></name> and <name><surname>Arnett</surname><given-names>C</given-names></name>. <article-title>The importance of bites by the saw-scaled or carpet viper (Echis carinatus)</article-title>. <source>Epidemiological studies in Nigeria and a review of world literature Acta Tropica</source><year>1976</year>; <volume>33</volume>, <fpage>307</fpage>–<lpage>341</lpage>.</mixed-citation></ref><ref id="pntd.0004568.ref002"><label>2</label><mixed-citation publication-type="journal"><name><surname>Visser</surname><given-names>L.E.</given-names></name>, <name><surname>Kyei-Faried</surname><given-names>S.</given-names></name>, <name><surname>Belcher</surname><given-names>D.W.</given-names></name>, <etal>et al</etal><article-title>Protocol and monitoring to improve snake bite outcomes in rural Ghana</article-title>. <source>Trans. R. Soc. Trop. Med. Hyg</source>. <year>2004</year>; <volume>98</volume>: <fpage>278</fpage>–<lpage>283</lpage>. <pub-id pub-id-type="pmid">15109550</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref003"><label>3</label><mixed-citation publication-type="journal"><name><surname>Enwere</surname><given-names>GC</given-names></name>, <name><surname>Obu</surname><given-names>HA</given-names></name>, <name><surname>Jobarteh</surname><given-names>A</given-names></name>. <article-title>Snake bites in children in The Gambia</article-title>. <source>Ann Trop Paediatr</source>. <year>2000</year><month>6</month>;<volume>20</volume>(<issue>2</issue>):<fpage>121</fpage>–<lpage>4</lpage>. (14.3%) <pub-id pub-id-type="pmid">10945062</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref004"><label>4</label><mixed-citation publication-type="journal"><name><surname>Fayomi</surname><given-names>B</given-names></name>, <name><surname>Massougbodji</surname><given-names>A</given-names></name>, <name><surname>Chobli</surname><given-names>M</given-names></name>. <article-title>Epidemiological data on snake bite cases reported in Benin from 1994 to 2000</article-title>. <source>Bull Soc Pathol Exot</source>. <year>2002</year><month>8</month>;<volume>95</volume>(<issue>3</issue>):<fpage>178</fpage>–<lpage>80</lpage>. (15% lethality) <pub-id pub-id-type="pmid">12404865</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref005"><label>5</label><mixed-citation publication-type="journal"><name><surname>Trape</surname><given-names>JF</given-names></name>, <name><surname>Pison</surname><given-names>G</given-names></name>, <name><surname>Guyavarch</surname><given-names>E</given-names></name>, <name><surname>Mane</surname><given-names>Y</given-names></name>. <article-title>Mortality from snake bites, wild and domestic animal bites and arthropod stings in the savannah zone of eastern Senegal</article-title>. <source>Bull Soc Pathol Exot</source>. <year>2002</year><month>8</month>;<volume>95</volume>(<issue>3</issue>):<fpage>154</fpage>–<lpage>6</lpage> (40% echis) <pub-id pub-id-type="pmid">12404858</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref006"><label>6</label><mixed-citation publication-type="journal"><name><surname>Chippaux</surname><given-names>JP</given-names></name>, <name><surname>Massougbodji</surname><given-names>A</given-names></name>, <name><surname>Stock</surname><given-names>RP</given-names></name>, <name><surname>Alagon</surname><given-names>A</given-names></name>; <collab>Investigators of African Antivipmyn in Benin</collab>. <article-title>Clinical trial of an F(ab')2 polyvalent equine antivenom for African snake bites in Benin</article-title>. <source>Am J Trop Med Hyg</source>. <year>2007</year><month>9</month>;<volume>77</volume>(<issue>3</issue>):<fpage>538</fpage>–<lpage>46</lpage>. (post AV mortality 3.11%) <pub-id pub-id-type="pmid">17827375</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref007"><label>7</label><mixed-citation publication-type="journal"><name><surname>Chippaux</surname><given-names>J-P</given-names></name>. <article-title>Estimate of the burden of snakebites in sub-Saharan Africa: A meta-analytic approach</article-title>. <source>Toxicon</source><year>2011</year>.</mixed-citation></ref><ref id="pntd.0004568.ref008"><label>8</label><mixed-citation publication-type="journal"><name><surname>Kasturiratne</surname><given-names>A</given-names></name>, <name><surname>Wickremasinghe</surname><given-names>AR</given-names></name>, <name><surname>de Silva</surname><given-names>NR</given-names></name>, <etal>et al</etal><article-title>The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths</article-title>. <source>PLoS Medicine</source><year>2008</year>; <volume>5</volume> (<issue>11</issue>): <fpage>1591</fpage>–<lpage>1604</lpage></mixed-citation></ref><ref id="pntd.0004568.ref009"><label>9</label><mixed-citation publication-type="journal"><name><surname>Pugh</surname><given-names>RNH</given-names></name> and <name><surname>Theakston</surname><given-names>RDG</given-names></name>. <article-title>Incidence and mortality of snake bite in savannah Nigeria</article-title>. <source>Lancet</source><year>1980</year>; <volume>2</volume>, <fpage>1181</fpage>–<lpage>3</lpage>. <pub-id pub-id-type="pmid">6107780</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref010"><label>10</label><mixed-citation publication-type="journal"><name><surname>Warrell</surname><given-names>DA</given-names></name>, <name><surname>Davidson</surname><given-names>NMcD</given-names></name>, <name><surname>Greenwood</surname><given-names>BM</given-names></name><etal>et al</etal><article-title>Poisoning by bites of the saw-scaled or carpet viper (Echis carinatus) in Nigeria</article-title>. <source>Quart. J. Med (ns)</source><year>1977</year>; <volume>46</volume>, <fpage>33</fpage>–<lpage>62</lpage>.</mixed-citation></ref><ref id="pntd.0004568.ref011"><label>11</label><mixed-citation publication-type="journal"><name><surname>Meyer</surname><given-names>WP</given-names></name>, <name><surname>Habib</surname><given-names>AG</given-names></name>. <name><surname>Onayade</surname><given-names>AA</given-names></name><etal>et al</etal><article-title>First clinical experience with a new ovine Fab Echis ocellatus snake bites antivenom in Nigeria. Randomized comparative trial with institute Pasteur Serum (IPSer) Africa antivenom</article-title><source>Amer, J. Trop. Med & Hyg</source>. <year>1997</year>; <volume>56</volume>(<issue>3</issue>), <fpage>292</fpage>–<lpage>300</lpage>.</mixed-citation></ref><ref id="pntd.0004568.ref012"><label>12</label><mixed-citation publication-type="journal"><name><surname>Warrell</surname><given-names>DA</given-names></name>, <name><surname>Barnes</surname><given-names>HJ</given-names></name> and <name><surname>Pirburn</surname><given-names>MF</given-names></name>, <article-title>Neurotoxic effects of bites by the Egyptian cobra (Naja haje) in Nigeria</article-title><year>1974</year><source>Trans. Roy. Soc. Trop. Med & Hyg</source>. 1974; <volume>70</volume>, <fpage>78</fpage>–<lpage>80</lpage>.<pub-id pub-id-type="pmid">1265823</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref013"><label>13</label><mixed-citation publication-type="journal"><name><surname>Pugh</surname><given-names>RNH</given-names></name>, <name><surname>Theakston</surname><given-names>RDG</given-names></name>, <name><surname>Reid</surname><given-names>HA</given-names></name> and <name><surname>Bhar</surname><given-names>IS</given-names></name>. <article-title>Malumfashi endemic diseases research project XIII. Epidemiology of human encounters with the spitting cobra (Naja nigricollis) in the Malumfashi area of northern Nigeria</article-title>. <source>Ann. Trop. Med. & Parasitol</source>. <year>1980</year>; <volume>74</volume>,<fpage>523</fpage>–<lpage>30</lpage>.<pub-id pub-id-type="pmid">7469568</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref014"><label>14</label><mixed-citation publication-type="journal"><name><surname>Muguti</surname><given-names>GI</given-names></name>, <name><surname>Maramba</surname><given-names>A</given-names></name>, <name><surname>Washaya</surname><given-names>CT</given-names></name>. <article-title>Snakebites in Zimbabwe: a clinical study with emphasis on the need for antivenom</article-title>. <source>Central African Journal of Medicine</source><year>1994</year>; <volume>40</volume>(<issue>4</issue>): <fpage>83</fpage>–<lpage>8</lpage><pub-id pub-id-type="pmid">7954715</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref015"><label>15</label><mixed-citation publication-type="journal"><name><surname>Warrell</surname><given-names>DA</given-names></name>, <name><surname>Ormerod</surname><given-names>LD</given-names></name> and <name><surname>Davidson</surname><given-names>NMcD</given-names></name>. <article-title>Bites by puff adder (Bitis arietans) in Nigeria and value of antivenom</article-title>. <source>Brit. Med. Journ</source>. <year>1975</year>; <volume>4</volume>, <fpage>697</fpage>–<lpage>700</lpage>.</mixed-citation></ref><ref id="pntd.0004568.ref016"><label>16</label><mixed-citation publication-type="journal"><name><surname>Warrell</surname><given-names>DA</given-names></name>, <name><surname>Ormerod</surname><given-names>LD</given-names></name> and <name><surname>Davidson</surname><given-names>NMcD</given-names></name>. <article-title>Bites by night adder (Causus maculatus) and burrowing vipers (Genus Atractaspis) in Nigeria</article-title><year>1976</year><source>Am Jour. Trop. Med. & Hyg</source>. 1976; <volume>25</volume>, <fpage>517</fpage>–<lpage>524</lpage>.<pub-id pub-id-type="pmid">945703</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref017"><label>17</label><mixed-citation publication-type="journal"><name><surname>Warrell</surname><given-names>DA</given-names></name>, <name><surname>Greenwood</surname><given-names>BM</given-names></name>, <name><surname>Davidson</surname><given-names>NMcD</given-names></name><etal>et al</etal><article-title>Necrosis, haemorrhage and complement depletion following bites by the spitting cobra (Naja nigricollis)</article-title><year>1976</year><source>Quart. J Med (ns)</source> 1976; <volume>45</volume>, <fpage>1</fpage>–<lpage>22</lpage>.</mixed-citation></ref><ref id="pntd.0004568.ref018"><label>18</label><mixed-citation publication-type="journal"><name><surname>Warrell</surname><given-names>DA</given-names></name> and <name><surname>Ormerod</surname><given-names>LD</given-names></name>. <article-title>Snake venom ophthalmia and blindness caused by the spitting cobra (Naja nigricollis) in Nigeria</article-title><year>1976</year><source>Amer. J. Trop. Med & Hyg</source>. 1976c; <volume>25</volume>, <fpage>525</fpage>–<lpage>529</lpage>.<pub-id pub-id-type="pmid">1084700</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref019"><label>19</label><mixed-citation publication-type="journal"><name><surname>Mustapha</surname><given-names>SK</given-names></name>, <name><surname>Mubi</surname><given-names>BM</given-names></name>, <name><surname>Askira</surname><given-names>BH</given-names></name>. <article-title>Bilateral blindness following snakebite</article-title>. <source>Trop Doct</source>. <year>2010</year><month>4</month>;<volume>40</volume>(<issue>2</issue>):<fpage>117</fpage>–<lpage>8</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1258/td.2009.090429">10.1258/td.2009.090429</ext-link></comment><pub-id pub-id-type="pmid">20305112</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref020"><label>20</label><mixed-citation publication-type="journal"><name><surname>Habib</surname><given-names>AG</given-names></name>, <name><surname>Abubakar</surname><given-names>SB</given-names></name>, <name><surname>Abubakar</surname><given-names>IS</given-names></name>, <name><surname>Larnyang</surname><given-names>S</given-names></name>, <name><surname>Durfa</surname><given-names>N</given-names></name>, <name><surname>Nasidi</surname><given-names>A</given-names></name>, <name><surname>Yusuf</surname><given-names>PO</given-names></name>, <name><surname>Garnvwa</surname><given-names>J</given-names></name>, <name><surname>Theakston</surname><given-names>RDG</given-names></name>, <name><surname>Salako</surname><given-names>L</given-names></name>, <name><surname>Warrell</surname><given-names>DA</given-names></name>. <article-title>Envenoming following carpet viper (Echis ocellatus) bite during pregnancy: timely use of effective antivenom improves materno-fetal outcomes</article-title>. <source>Tropical Medicine and International Health</source><year>2008</year>; <volume>13</volume>(<issue>9</issue>): <fpage>1172</fpage>–<lpage>5</lpage><comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1111/j.1365-3156.2008.02122.x">10.1111/j.1365-3156.2008.02122.x</ext-link></comment><pub-id pub-id-type="pmid">18631310</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref021"><label>21</label><mixed-citation publication-type="journal"><name><surname>Williams</surname><given-names>SS</given-names></name>, <name><surname>Wijesinghe</surname><given-names>CA</given-names></name>, <name><surname>Jayamanne</surname><given-names>SF</given-names></name>, <name><surname>Buckley</surname><given-names>NA</given-names></name>, <name><surname>Dawson</surname><given-names>AH</given-names></name>, <name><surname>Lalloo</surname><given-names>DG</given-names></name>, <name><surname>de Silva</surname><given-names>HJ</given-names></name>. <article-title>Delayed Psychological Morbidity Associated with Snakebite Envenoming</article-title>. <source>PLoS Neg Trop Dis</source><year>2011</year>; <volume>5</volume>(<issue>8</issue>): <fpage>e1255</fpage>.</mixed-citation></ref><ref id="pntd.0004568.ref022"><label>22</label><mixed-citation publication-type="journal"><name><surname>Habib</surname><given-names>AG</given-names></name> and <name><surname>Warrell</surname><given-names>DA</given-names></name>. <article-title>Antivenom therapy of carpet viper (Echis ocellatus) envenoming: effectiveness and strategies for delivery in West Africa</article-title>. <source>Toxicon</source><year>2013</year>;<volume>69</volume>:<fpage>82</fpage>–<lpage>89</lpage><comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1016/j.toxicon.2013.01.002">10.1016/j.toxicon.2013.01.002</ext-link></comment><pub-id pub-id-type="pmid">23339853</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref023"><label>23</label><mixed-citation publication-type="journal"><name><surname>Abubakar</surname><given-names>IS</given-names></name>, <name><surname>Abubakar</surname><given-names>SB</given-names></name>, <name><surname>Habib</surname><given-names>AG</given-names></name>, <name><surname>Nasidi</surname><given-names>A</given-names></name>, <name><surname>Durfa</surname><given-names>N</given-names></name>, <name><surname>Yusuf</surname><given-names>PO</given-names></name>, <name><surname>Larnyang</surname><given-names>S</given-names></name>, <name><surname>Garnvwa</surname><given-names>J</given-names></name>, <name><surname>Sokomba</surname><given-names>E</given-names></name>, <name><surname>Salako</surname><given-names>L</given-names></name>, <name><surname>Theakston</surname><given-names>RD</given-names></name>, <name><surname>Juszczak</surname><given-names>E</given-names></name>, <name><surname>Alder</surname><given-names>N</given-names></name>, <name><surname>Warrell</surname><given-names>DA</given-names></name>; <collab>Nigeria-UK EchiTab Study Group</collab>. <year>2010</year><article-title>Randomised controlled double-blind non-inferiority trial of two antivenoms for saw-scaled or carpet viper (Echis ocellatus) envenoming in Nigeria</article-title>. <source>PLoS Negl Trop Dis</source>. <volume>4</volume>(<issue>7</issue>):<fpage>e767</fpage><comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1371/journal.pntd.0000767">10.1371/journal.pntd.0000767</ext-link></comment><pub-id pub-id-type="pmid">20668549</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref024"><label>24</label><mixed-citation publication-type="journal"><name><surname>Williams</surname><given-names>DJ</given-names></name>, <name><surname>Jensen</surname><given-names>SD</given-names></name>, <name><surname>Nimorakiotakis</surname><given-names>B</given-names></name>, <name><surname>Müller</surname><given-names>R</given-names></name>, <name><surname>Winkel</surname><given-names>KD</given-names></name>. <article-title>Antivenom use, premedication and early adverse reactions in the management of snake bites in rural Papua New Guinea</article-title>. <source>Toxicon</source>. <year>2007</year><month>5</month>;<volume>49</volume>(<issue>6</issue>):<fpage>780</fpage>–<lpage>92</lpage>. Epub 2006 Dec 2. <pub-id pub-id-type="pmid">17210167</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref025"><label>25</label><mixed-citation publication-type="journal"><name><surname>Habib</surname><given-names>AG</given-names></name>. <article-title>Effect of pre-medication on early adverse reactions following antivenom use in snakebite: a systematic review and meta-analysis</article-title>. <source>Drug Saf</source>. <year>2011</year><month>10</month><day>1</day>;<volume>34</volume>(<issue>10</issue>):<fpage>869</fpage>–<lpage>80</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.2165/11592050-000000000-00000">10.2165/11592050-000000000-00000</ext-link></comment><pub-id pub-id-type="pmid">21879781</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref026"><label>26</label><mixed-citation publication-type="journal"><name><surname>de Silva</surname><given-names>HA</given-names></name>, <name><surname>Pathmeswaran</surname><given-names>A</given-names></name>, <name><surname>Ranasinha</surname><given-names>CD</given-names></name>, <name><surname>Jayamanne</surname><given-names>S</given-names></name>, <name><surname>Samarakoon</surname><given-names>snakebite</given-names></name>, <name><surname>Hittharage</surname><given-names>A</given-names></name>, <name><surname>Kalupahana</surname><given-names>R</given-names></name>, <name><surname>Ratnatilaka</surname><given-names>GA</given-names></name>, <name><surname>Uluwatthage</surname><given-names>W</given-names></name>, <name><surname>Aronson</surname><given-names>JK</given-names></name>, <name><surname>Armitage</surname><given-names>JM</given-names></name>, <name><surname>Lalloo</surname><given-names>DG</given-names></name>, <name><surname>de Silva</surname><given-names>HJ</given-names></name>. <article-title>Low-dose adrenaline, promethazine, and hydrocortisone in the prevention of acute adverse reactions to antivenom following snakebite: a randomised, double-blind, placebo-controlled trial</article-title>. <source>PLoS Med</source>. <year>2011</year><month>5</month>;<volume>8</volume>(<issue>5</issue>):<fpage>e1000435</fpage><comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1371/journal.pmed.1000435">10.1371/journal.pmed.1000435</ext-link></comment><pub-id pub-id-type="pmid">21572992</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref027"><label>27</label><mixed-citation publication-type="other">EchiTab study group on monospecific antivenom; <ext-link ext-link-type="uri" xlink:href="http://www.lstmliverpool.ac.uk/research/departments/parasitology/venom-unit/echitab-study-group/">http://www.lstmliverpool.ac.uk/research/departments/parasitology/venom-unit/echitab-study-group/</ext-link> (accessed on 8 Aug 2015)</mixed-citation></ref><ref id="pntd.0004568.ref028"><label>28</label><mixed-citation publication-type="other">EchiTab IgG Plus ICP Polyspecific antivenom product description. <ext-link ext-link-type="uri" xlink:href="http://www.echitabplusicp.org/product/description.html">http://www.echitabplusicp.org/product/description.html</ext-link> (accessed on 8 Aug 2015)</mixed-citation></ref><ref id="pntd.0004568.ref029"><label>29</label><mixed-citation publication-type="journal"><name><surname>Brown</surname><given-names>NI</given-names></name>. <article-title>Consequences of neglect: analysis of the sub-Saharan African snake antivenom market and the global context</article-title>. <source>PLoS Negl Trop Dis</source>. <year>2012</year>;<volume>6</volume>:<fpage>e1670</fpage><comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1371/journal.pntd.0001670">10.1371/journal.pntd.0001670</ext-link></comment><pub-id pub-id-type="pmid">22679521</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref030"><label>30</label><mixed-citation publication-type="journal"><name><surname>Dramé</surname><given-names>BS</given-names></name>, <name><surname>Dabo</surname><given-names>M</given-names></name>, <name><surname>Diani</surname><given-names>N</given-names></name>, <name><surname>Cissé</surname><given-names>B</given-names></name>. <article-title>Assessment of the availability and use of antivenom in the district of Bamako,Mali, West Africa</article-title>. <source>Bull Soc Pathol Exot</source>. <year>2012</year><month>8</month>;<volume>105</volume>(<issue>3</issue>):<fpage>179</fpage>–<lpage>83</lpage>. <pub-id pub-id-type="pmid">22707256</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref031"><label>31</label><mixed-citation publication-type="book"><collab>Management Sciences for Health</collab>. <source>International Drug Price Indicator Guide</source>. <year>2012</year> edition. <publisher-loc>Cambridge, MA, USA</publisher-loc>: <publisher-name>Management Sciences for Health</publisher-name>; 2013.</mixed-citation></ref><ref id="pntd.0004568.ref032"><label>32</label><mixed-citation publication-type="journal"><name><surname>Chippaux</surname><given-names>JP</given-names></name>, <name><surname>Habib</surname><given-names>AG</given-names></name>. <article-title>Antivenom shortage is not circumstantial but structural</article-title>. <source>Trans R Soc Trop Med Hyg</source>. <year>2015</year><month>12</month>;<volume>109</volume>(<issue>12</issue>):<fpage>747</fpage>–<lpage>8</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1093/trstmh/trv088">10.1093/trstmh/trv088</ext-link></comment><pub-id pub-id-type="pmid">26626337</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref033"><label>33</label><mixed-citation publication-type="journal"><name><surname>Habib</surname><given-names>AG</given-names></name>, <name><surname>Lamorde</surname><given-names>M</given-names></name>, <name><surname>Dalhat</surname><given-names>MM</given-names></name>, <name><surname>Habib</surname><given-names>ZG</given-names></name>, <name><surname>Kuznik</surname><given-names>A</given-names></name>. <article-title>Cost-effectiveness of Antivenoms for Snakebite Envenoming in Nigeria</article-title>. <source>PLoS Neglected Tropical Diseases</source><year>2015</year>; <volume>9</volume>(<issue>1</issue>):<fpage>e3381</fpage><comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1371/journal.pntd.0003381">10.1371/journal.pntd.0003381</ext-link></comment><pub-id pub-id-type="pmid">25569252</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref034"><label>34</label><mixed-citation publication-type="journal"><name><surname>Morais</surname><given-names>V</given-names></name>, <name><surname>Massaldi</surname><given-names>H</given-names></name>. <article-title>Economic evaluation of snake antivenom production in the public system</article-title>. <source>Journal of Venomous Animals and Toxins including Tropical Diseases</source><year>2006</year>; <volume>3</volume>: <fpage>497</fpage>–<lpage>511</lpage></mixed-citation></ref><ref id="pntd.0004568.ref035"><label>35</label><mixed-citation publication-type="journal"><name><surname>Brown</surname><given-names>N</given-names></name> and <name><surname>Landon</surname><given-names>J</given-names></name>. <article-title>Antivenom: The most cost-effective treatment in the world?</article-title><source>Toxicon</source><year>2010</year>; <volume>55</volume>: <fpage>1405</fpage>–<lpage>7</lpage><comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1016/j.toxicon.2010.02.012">10.1016/j.toxicon.2010.02.012</ext-link></comment><pub-id pub-id-type="pmid">20171241</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref036"><label>36</label><mixed-citation publication-type="journal"><name><surname>Chippaux</surname><given-names>JP</given-names></name>, <name><surname>Lang</surname><given-names>J</given-names></name>, <name><surname>Amadi-Eddine</surname><given-names>S</given-names></name>, <name><surname>Fagot</surname><given-names>P</given-names></name>, <name><surname>Le Mener</surname><given-names>V</given-names></name>. <article-title>Short report: treatment of snake envenomations by a new polyvalent antivenom composed of highly purified F(ab)2: results of a clinical trial in northern Cameroon</article-title>. <source>Am J Trop Med Hyg</source>. <year>1999</year><month>12</month>;<volume>61</volume>(<issue>6</issue>):<fpage>1017</fpage>–<lpage>8</lpage><pub-id pub-id-type="pmid">10674688</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref037"><label>37</label><mixed-citation publication-type="journal"><name><surname>Baldé</surname><given-names>MC</given-names></name>, <name><surname>Chippaux</surname><given-names>JP</given-names></name>, <name><surname>Boiro</surname><given-names>MY</given-names></name>, <name><surname>Stock</surname><given-names>R</given-names></name>, <name><surname>Massougbodji</surname><given-names>A</given-names></name>. <article-title>Clinical study of tolerance and effectiveness of a F(ab')(2) polyvalent antienom for African snake bites in Kindia, Guinea</article-title>. <source>Bull Soc Pathol Exot</source>. <year>2012</year><month>8</month>;<volume>105</volume>(<issue>3</issue>):<fpage>157</fpage>–<lpage>61</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1007/s13149-012-0223-3">10.1007/s13149-012-0223-3</ext-link></comment> Epub 2012 Feb 22 <pub-id pub-id-type="pmid">22359185</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref038"><label>38</label><mixed-citation publication-type="journal"><name><surname>Habib</surname><given-names>AG</given-names></name>, <name><surname>Abubakar</surname><given-names>SB</given-names></name><year>2011</year><article-title>Factors affecting snakebite mortality in north-eastern Nigeria</article-title>. <source>International Health</source>. <volume>3</volume>: <fpage>50</fpage>–<lpage>55</lpage><comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1016/j.inhe.2010.08.001">10.1016/j.inhe.2010.08.001</ext-link></comment><pub-id pub-id-type="pmid">24038050</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref039"><label>39</label><mixed-citation publication-type="journal"><name><surname>Bregani</surname><given-names>ER</given-names></name>, <name><surname>Cantoni</surname><given-names>F</given-names></name>, <name><surname>Tantardini</surname><given-names>F</given-names></name><year>2006</year><article-title>Snake bites in South Chad. Comparison between three different polyvalent anti-snake venom immunotherapies</article-title>. <source>Italian Journal of Tropical Medicine</source><volume>11</volume>: (<issue>1–2</issue>); <fpage>25</fpage>–<lpage>28</lpage></mixed-citation></ref><ref id="pntd.0004568.ref040"><label>40</label><mixed-citation publication-type="journal"><name><surname>Visser</surname><given-names>LE</given-names></name>, <name><surname>Kyei-Faried</surname><given-names>S</given-names></name>, <name><surname>Belcher</surname><given-names>DW</given-names></name>, <name><surname>Geelhoed</surname><given-names>DW</given-names></name>, <name><surname>van Leeuwen</surname><given-names>JS</given-names></name>, <name><surname>van Roosmalen</surname><given-names>J</given-names></name>, <year>2008</year><article-title>Failure of a new antivenom to treat Echis ocellatus snake bite in rural Ghana: the importance of quality surveillance</article-title>. <source>Trans R Soc Trop Med Hyg</source><volume>102</volume>(<issue>5</issue>):<fpage>445</fpage>–<lpage>50</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1016/j.trstmh.2007.11.006">10.1016/j.trstmh.2007.11.006</ext-link></comment><pub-id pub-id-type="pmid">18190937</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref041"><label>41</label><mixed-citation publication-type="journal"><name><surname>Dramé</surname><given-names>BS</given-names></name>, <name><surname>Diarra</surname><given-names>A</given-names></name>, <name><surname>Diani</surname><given-names>N</given-names></name>, <name><surname>Dabo</surname><given-names>A</given-names></name>. <article-title>Epidemiological, clinical and therapeutics aspects of snakebites in the Gabriel-Touré and Kati national hospitals of Mali: a ten-year retrospective study</article-title>. <source>Bull Soc Pathol Exot</source>. <year>2012</year><month>8</month>;<volume>105</volume>(<issue>3</issue>):<fpage>184</fpage>–<lpage>8</lpage>. Epub 2012 Jun 16 <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1007/s13149-012-0240-2">10.1007/s13149-012-0240-2</ext-link></comment><pub-id pub-id-type="pmid">22707257</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref042"><label>42</label><mixed-citation publication-type="journal"><name><surname>Baldé</surname><given-names>MC</given-names></name>, <name><surname>Chippaux</surname><given-names>JP</given-names></name>, <name><surname>Boiro</surname><given-names>MY</given-names></name>, <name><surname>Stock</surname><given-names>RP</given-names></name>, <name><surname>Massougbodji</surname><given-names>A</given-names></name>. <article-title>Use of antivenoms for the treatment of envenomation by Elapidae snakes in Guinea, Sub-Saharan Africa</article-title>. <source>J Venom Anim Toxins Incl Trop Dis</source>. <year>2013</year><month>3</month><day>28</day>;<volume>19</volume>(<issue>1</issue>):<fpage>6</fpage><comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1186/1678-9199-19-6">10.1186/1678-9199-19-6</ext-link></comment><pub-id pub-id-type="pmid">23849079</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref043"><label>43</label><mixed-citation publication-type="journal"><name><surname>Laohawiriyakamol</surname><given-names>S</given-names></name>, <name><surname>Sangkhathat</surname><given-names>S</given-names></name>, <name><surname>Chiengkriwate</surname><given-names>P</given-names></name>, <name><surname>Patrapinyokul</surname><given-names>S</given-names></name>. <article-title>Surgery in management of snake envenomation in children</article-title>. <source>World J Pediatr</source>. <year>2011</year><month>11</month>;<volume>7</volume>(<issue>4</issue>):<fpage>361</fpage>–<lpage>4</lpage>. Epub 2011 Aug 27. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1007/s12519-011-0282-8">10.1007/s12519-011-0282-8</ext-link></comment><pub-id pub-id-type="pmid">21877258</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref044"><label>44</label><mixed-citation publication-type="journal"><name><surname>Yates</surname><given-names>VM</given-names></name>, <name><surname>Lebas</surname><given-names>E</given-names></name>, <name><surname>Orpiay</surname><given-names>R</given-names></name>, <name><surname>Bale</surname><given-names>BJ</given-names></name>. <article-title>Management of snakebites by the staff of a rural clinic: the impact of providing free antivenom in a nurse-led clinic in Meserani, Tanzania</article-title>. <source>Ann Trop Med Parasitol</source>. <year>2010</year><month>7</month>;<volume>104</volume>(<issue>5</issue>):<fpage>439</fpage>–<lpage>48</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1179/136485910X12743554760306">10.1179/136485910X12743554760306</ext-link></comment><pub-id pub-id-type="pmid">20819312</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref045"><label>45</label><mixed-citation publication-type="journal"><name><surname>Adehossi</surname><given-names>E</given-names></name>, <name><surname>Sani</surname><given-names>R</given-names></name>, <name><surname>Boukari-Bawa</surname><given-names>M</given-names></name>, <name><surname>Niaouro</surname><given-names>S</given-names></name>, <name><surname>Gbaguidi</surname><given-names>F</given-names></name>, <name><surname>Abdou</surname><given-names>I</given-names></name>, <name><surname>Parola</surname><given-names>P</given-names></name>. <article-title>Snake bites in the emergency unit of Niamey National Hospital, Niger</article-title>. <source>Bull Soc Pathol Exot</source>. <year>2011</year><month>12</month>;<volume>104</volume>(<issue>5</issue>):<fpage>357</fpage>–<lpage>60</lpage>. Epub 2011 Aug 1.<pub-id pub-id-type="pmid">21809217</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref046"><label>46</label><mixed-citation publication-type="journal"><name><surname>Habib</surname><given-names>AG</given-names></name>, <name><surname>Kuznik</surname><given-names>A</given-names></name>, <name><surname>Hamza</surname><given-names>M</given-names></name>, <name><surname>Abdullahi</surname><given-names>MI</given-names></name>, <name><surname>Chedi</surname><given-names>BA</given-names></name>, <name><surname>Chippaux</surname><given-names>JP</given-names></name>, <name><surname>Warrell</surname><given-names>DA</given-names></name>. <article-title>Snakebite is Under Appreciated: Appraisal of Burden from West Africa</article-title>. <source>PLoS Negl Trop Dis</source>. <year>2015</year><month>9</month><day>23</day>;<volume>9</volume>(<issue>9</issue>):<fpage>e0004088</fpage><comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1371/journal.pntd.0004088">10.1371/journal.pntd.0004088</ext-link></comment><pub-id pub-id-type="pmid">26398046</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref047"><label>47</label><mixed-citation publication-type="other">World Health Organization. Mortality and life expectancy data Nigeria. Global Health Observatory, WHO, 2012. <ext-link ext-link-type="uri" xlink:href="http://apps.who.int/gho/athena/data/download.xsl?format=xml&target=GHO/LIFE_0000000029,LIFE_0000000030,LIFE_0000000031,LIFE_0000000032,LIFE_0000000033,LIFE_0000000034,LIFE_0000000035&profile=excel&filter=COUNTRY:XYZ">http://apps.who.int/gho/athena/data/download.xsl?format=xml&target=GHO/LIFE_0000000029,LIFE_0000000030,LIFE_0000000031,LIFE_0000000032,LIFE_0000000033,LIFE_0000000034,LIFE_0000000035&profile=excel&filter=COUNTRY:XYZ</ext-link></mixed-citation></ref><ref id="pntd.0004568.ref048"><label>48</label><mixed-citation publication-type="other">World Health Organization. Global Burden of Disease 2004 Update: Disability weights for diseases and conditions, WHO</mixed-citation></ref><ref id="pntd.0004568.ref049"><label>49</label><mixed-citation publication-type="book"><name><surname>Hunink</surname><given-names>MG</given-names></name> and <name><surname>Glasziou</surname><given-names>P</given-names></name><year>2001</year><source>Decision making in health and medicine</source>. <publisher-name>Cambridge University Press</publisher-name>, pp <fpage>1</fpage>–<lpage>388</lpage></mixed-citation></ref><ref id="pntd.0004568.ref050"><label>50</label><mixed-citation publication-type="journal"><name><surname>Fox-Rushby</surname><given-names>JA</given-names></name> and <name><surname>Hanson</surname><given-names>K</given-names></name>. <article-title>Calculating and presenting disability adjusted life years (DALYs) in cost-effectiveness analysis</article-title>. <source>Health Policy and Planning</source><year>2001</year>; <volume>16</volume>(<issue>3</issue>): <fpage>326</fpage>–<lpage>331</lpage>. <pub-id pub-id-type="pmid">11527874</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref051"><label>51</label><mixed-citation publication-type="book"><collab>World Bank</collab><year>2012</year><source>GDP per capita</source>. <publisher-loc>Washington, DC</publisher-loc>: <publisher-name>World Bank</publisher-name>—<ext-link ext-link-type="uri" xlink:href="http://data.worldbank.org/indicator/NY.GDP.PCAP.CD">http://data.worldbank.org/indicator/NY.GDP.PCAP.CD</ext-link> (accessed 13 June 2015)</mixed-citation></ref><ref id="pntd.0004568.ref052"><label>52</label><mixed-citation publication-type="book"><collab>World Health Organization</collab>. <source>Cost effectiveness thresholds</source>. <publisher-loc>Geneva</publisher-loc>: <publisher-name>World Health Organization</publisher-name>, <year>2011</year>.</mixed-citation></ref><ref id="pntd.0004568.ref053"><label>53</label><mixed-citation publication-type="journal"><name><surname>Siegel</surname><given-names>JE</given-names></name>, <name><surname>Weinstein</surname><given-names>MC</given-names></name>, <name><surname>Russell</surname><given-names>LB</given-names></name>, <name><surname>Gold</surname><given-names>MR</given-names></name>. <article-title>Recommendations for reporting cost-effectiveness analyses. Panel on Cost-Effectiveness in Health and Medicine</article-title>. <source>JAMA</source>. <year>1996</year><month>10</month><day>23–30</day>;<volume>276</volume>(<issue>16</issue>):<fpage>1339</fpage>–<lpage>41</lpage>. <pub-id pub-id-type="pmid">8861994</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref054"><label>54</label><mixed-citation publication-type="journal"><name><surname>Husereau</surname><given-names>D</given-names></name>, <name><surname>Drummond</surname><given-names>M</given-names></name>, <name><surname>Petrou</surname><given-names>S</given-names></name>, <name><surname>Carswell</surname><given-names>C</given-names></name>, <name><surname>Moher</surname><given-names>D</given-names></name>, <name><surname>Greenberg</surname><given-names>D</given-names></name>, <name><surname>Augustovski</surname><given-names>F</given-names></name>, <name><surname>Briggs</surname><given-names>AH</given-names></name>, <name><surname>Mauskopf</surname><given-names>J</given-names></name>, <name><surname>Loder</surname><given-names>E</given-names></name>. <article-title>Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement</article-title>. <source>Eur J Health Econ</source>. <year>2013</year>;<volume>14</volume>(<issue>3</issue>):<fpage>367</fpage>–<lpage>372</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1007/s10198-013-0471-6">10.1007/s10198-013-0471-6</ext-link></comment><pub-id pub-id-type="pmid">23526140</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref055"><label>55</label><mixed-citation publication-type="journal"><name><surname>Goldie</surname><given-names>SJ</given-names></name>, <name><surname>Yazdanpanah</surname><given-names>Y</given-names></name>, <name><surname>Losina</surname><given-names>E</given-names></name>, <name><surname>Weinstein</surname><given-names>MC</given-names></name>, <name><surname>Anglaret</surname><given-names>X</given-names></name>, <name><surname>Walensky</surname><given-names>RP</given-names></name>, <etal>et al</etal><article-title>Cost effectiveness of HIV treatment in resource-poor settings—the case of Cote d’Ivoire</article-title>. <source>N Engl J Med</source><year>2006</year>; <volume>355</volume>: <fpage>1141</fpage>–<lpage>1153</lpage><pub-id pub-id-type="pmid">16971720</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref056"><label>56</label><mixed-citation publication-type="journal"><name><surname>Long</surname><given-names>L</given-names></name>, <name><surname>Fox</surname><given-names>M</given-names></name>, <name><surname>Sanne</surname><given-names>I</given-names></name>, <name><surname>Rosen</surname><given-names>S</given-names></name>. <article-title>The high cost of second-line antiretroviral therapy for HIV/AIDS in South Africa</article-title>. <source>AIDS</source><year>2010</year>; <volume>24</volume>: <fpage>915</fpage>–<lpage>919</lpage><comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1097/QAD.0b013e3283360976">10.1097/QAD.0b013e3283360976</ext-link></comment><pub-id pub-id-type="pmid">20042849</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref057"><label>57</label><mixed-citation publication-type="journal"><name><surname>Walensky</surname><given-names>RP</given-names></name>, <name><surname>Ross</surname><given-names>EL</given-names></name>, <name><surname>Kumarasamy</surname><given-names>N</given-names></name>, <name><surname>Wood</surname><given-names>R</given-names></name>, <name><surname>Noubary</surname><given-names>F</given-names></name>, <name><surname>Paltiel</surname><given-names>D</given-names></name>, <etal>et al</etal><article-title>Cost effectiveness of HIV treatment as prevention in serodiscordant couples</article-title>. <source>N Engl J Med</source><year>2013</year>; <volume>369</volume>: <fpage>1715</fpage>–<lpage>1725</lpage><comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1056/NEJMsa1214720">10.1056/NEJMsa1214720</ext-link></comment><pub-id pub-id-type="pmid">24171517</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref058"><label>58</label><mixed-citation publication-type="journal"><name><surname>van Hoek</surname><given-names>AJ</given-names></name>, <name><surname>Ngama</surname><given-names>M</given-names></name>, <name><surname>Ismail</surname><given-names>A</given-names></name>, <name><surname>Chuma</surname><given-names>J</given-names></name>, <name><surname>Cheburet</surname><given-names>S</given-names></name>, <name><surname>Mutonga</surname><given-names>D</given-names></name>, <name><surname>Kamau</surname><given-names>T</given-names></name>, <name><surname>Nokes</surname><given-names>DJ</given-names></name>. <article-title>A cost effectiveness and capacity analysis for the introduction of universal rotavirus vaccination in Kenya: comparison between Rotarix and RotaTeq vaccines</article-title>. <source>PLoS One</source>. <year>2012</year>;<volume>7</volume>(<issue>10</issue>):<fpage>e47511</fpage> Epub 2012 Oct 24. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1371/journal.pone.0047511">10.1371/journal.pone.0047511</ext-link></comment><pub-id pub-id-type="pmid">23115650</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref059"><label>59</label><mixed-citation publication-type="journal"><name><surname>Patel</surname><given-names>HD</given-names></name>, <name><surname>Roberts</surname><given-names>ET</given-names></name>, <name><surname>Constela</surname><given-names>DO</given-names></name>. <article-title>Cost-effectiveness of a new rotavirus vaccination program in Pakistan: a decision tree model</article-title>. <source>Vaccine</source><year>2013</year>; <volume>31</volume>: <fpage>6072</fpage>–<lpage>8</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1016/j.vaccine.2013.10.022">10.1016/j.vaccine.2013.10.022</ext-link></comment><pub-id pub-id-type="pmid">24176497</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref060"><label>60</label><mixed-citation publication-type="journal"><name><surname>Goldie</surname><given-names>SJ</given-names></name>, <name><surname>O’Shea</surname><given-names>M</given-names></name>, <name><surname>Campos</surname><given-names>NG</given-names></name>, <name><surname>Dias</surname><given-names>M</given-names></name>, <name><surname>Sweet</surname><given-names>S</given-names></name>, <name><surname>Kim</surname><given-names>SY</given-names></name>. <article-title>Health and economic outcomes of HPV 16, 18 vaccination in 72 GAVI eligible countries</article-title>. <source>Vaccine</source><year>2008</year>; <volume>26</volume>(<issue>32</issue>): <fpage>4080</fpage>–<lpage>93</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1016/j.vaccine.2008.04.053">10.1016/j.vaccine.2008.04.053</ext-link></comment><pub-id pub-id-type="pmid">18550229</pub-id></mixed-citation></ref><ref id="pntd.0004568.ref061"><label>61</label><mixed-citation publication-type="journal"><name><surname>Sinha</surname><given-names>A</given-names></name>, <name><surname>Levine</surname><given-names>O</given-names></name>, <name><surname>Knoll</surname><given-names>MD</given-names></name>, <name><surname>Muhib</surname><given-names>F</given-names></name>, <name><surname>Lieu</surname><given-names>TA</given-names></name>. <article-title>Cost effectiveness of pneumococcal conjugate vaccination in the prevention of child mortality: an international economic analysis</article-title>. <source>Lancet</source><year>2007</year>; <volume>369</volume>:<fpage>389</fpage>–<lpage>96</lpage><pub-id pub-id-type="pmid">17276779</pub-id></mixed-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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