Evaluation of Cost-Effective Strategies for Rabies Post-Exposure Vaccination in Low-Income Countries
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{"title"=>"Evaluation of cost-effective strategies for rabies post-exposure vaccination in low-income countries", "type"=>"journal", "authors"=>[{"first_name"=>"Katie", "last_name"=>"Hampson", "scopus_author_id"=>"35617491900"}, {"first_name"=>"Sarah", "last_name"=>"Cleaveland", "scopus_author_id"=>"6602122886"}, {"first_name"=>"Deborah", "last_name"=>"Briggs", "scopus_author_id"=>"56530192200"}], "year"=>2011, "source"=>"PLoS Neglected Tropical Diseases", "identifiers"=>{"issn"=>"1935-2735", "scopus"=>"2-s2.0-79953784997", "sgr"=>"79953784997", "pui"=>"361572506", "isbn"=>"1935-2735 (Electronic)\\r1935-2727 (Linking)", "pmid"=>"21408121", "doi"=>"10.1371/journal.pntd.0000982"}, "id"=>"b452e342-2b8e-3637-b317-fa9fa97c9dd0", "abstract"=>"BACKGROUND: Prompt post-exposure prophylaxis (PEP) is essential in preventing the fatal onset of disease in persons exposed to rabies. Unfortunately, life-saving rabies vaccines and biologicals are often neither accessible nor affordable, particularly to the poorest sectors of society who are most at risk and upon whom the largest burden of rabies falls. Increasing accessibility, reducing costs and preventing delays in delivery of PEP should therefore be prioritized.\\n\\nMETHODOLOGY/PRINCIPAL FINDINGS: We analyzed different PEP vaccination regimens and evaluated their relative costs and benefits to bite victims and healthcare providers. We found PEP vaccination to be an extremely cost-effective intervention (from $200 to less than $60/death averted). Switching from intramuscular (IM) administration of PEP to equally efficacious intradermal (ID) regimens was shown to result in significant savings in the volume of vaccine required to treat the same number of patients, which could mitigate vaccine shortages, and would dramatically reduce the costs of implementing PEP. We present financing mechanisms that would make PEP more affordable and accessible, could help subsidize the cost for those most in need, and could even support new and existing rabies control and prevention programs.\\n\\nCONCLUSIONS/SIGNIFICANCE: We conclude that a universal switch to ID delivery would improve the affordability and accessibility of PEP for bite victims, leading to a likely reduction in human rabies deaths, as well as being economical for healthcare providers.", "link"=>"http://www.mendeley.com/research/evaluation-costeffective-strategies-rabies-postexposure-vaccination-lowincome-countries", "reader_count"=>92, "reader_count_by_academic_status"=>{"Professor > Associate Professor"=>2, "Researcher"=>31, "Student > Doctoral Student"=>5, "Student > Ph. D. Student"=>13, "Student > Postgraduate"=>13, "Student > Master"=>15, "Other"=>2, "Student > Bachelor"=>8, "Lecturer > Senior Lecturer"=>1, "Professor"=>2}, "reader_count_by_user_role"=>{"Professor > Associate Professor"=>2, "Researcher"=>31, "Student > Doctoral Student"=>5, "Student > Ph. D. Student"=>13, "Student > Postgraduate"=>13, "Student > Master"=>15, "Other"=>2, "Student > Bachelor"=>8, "Lecturer > Senior Lecturer"=>1, "Professor"=>2}, "reader_count_by_subject_area"=>{"Unspecified"=>2, "Agricultural and Biological Sciences"=>25, "Arts and Humanities"=>1, "Business, Management and Accounting"=>1, "Veterinary Science and Veterinary Medicine"=>8, "Chemistry"=>1, "Earth and Planetary Sciences"=>1, "Economics, Econometrics and Finance"=>7, "Environmental Science"=>1, "Nursing and Health Professions"=>2, "Mathematics"=>1, "Medicine and Dentistry"=>35, "Pharmacology, Toxicology and Pharmaceutical Science"=>1, "Psychology"=>1, "Social Sciences"=>4, "Immunology and Microbiology"=>1}, "reader_count_by_subdiscipline"=>{"Medicine and Dentistry"=>{"Medicine and Dentistry"=>35}, "Social Sciences"=>{"Social Sciences"=>4}, "Psychology"=>{"Psychology"=>1}, "Mathematics"=>{"Mathematics"=>1}, "Unspecified"=>{"Unspecified"=>2}, "Environmental Science"=>{"Environmental Science"=>1}, "Pharmacology, Toxicology and Pharmaceutical Science"=>{"Pharmacology, Toxicology and Pharmaceutical Science"=>1}, "Arts and Humanities"=>{"Arts and Humanities"=>1}, "Chemistry"=>{"Chemistry"=>1}, "Earth and Planetary Sciences"=>{"Earth and Planetary Sciences"=>1}, "Economics, Econometrics and Finance"=>{"Economics, Econometrics and Finance"=>7}, "Immunology and Microbiology"=>{"Immunology and Microbiology"=>1}, "Agricultural and Biological Sciences"=>{"Agricultural and Biological Sciences"=>25}, "Business, Management and Accounting"=>{"Business, Management and Accounting"=>1}, "Nursing and Health Professions"=>{"Nursing and Health Professions"=>2}, "Veterinary Science and Veterinary Medicine"=>{"Veterinary Science and Veterinary Medicine"=>8}}, "reader_count_by_country"=>{"United States"=>1, "Mali"=>1, "South Africa"=>2, "United Kingdom"=>2, "India"=>1}, "group_count"=>11}

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Figshare

  • {"files"=>["https://ndownloader.figshare.com/files/792452"], "description"=>"<p>Costs were calculated based on whether PEP vaccination is provided free-of-charge, or according to different pricing strategies. The most affordable regimens are emboldened for each strategy. We assume that for each clinic visit patients pay a consultation fee (that is equivalent to the price of overhead for a clinic visit) and the costs of materials for injections (<a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd-0000982-t002\" target=\"_blank\">Table 2</a>).</p>1<p>Low indirect costs are assumed to be $2.9/visit (best case scenario in <a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd-0000982-t002\" target=\"_blank\">Table 2</a>), corresponding to patients from urban areas that only need to travel relatively short distances to obtain PEP.</p>2<p>High indirect costs are assumed to be $14/visit (worst case scenario in <a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd-0000982-t002\" target=\"_blank\">Table 2</a>), which corresponds to patients from rural areas, that have to travel long-distances to a hospital and may need to stay overnight whilst seeking PEP.</p>*<p>For IM regimens, when patients pay for PEP vaccination we assume they pay $10/vial (<a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd-0000982-t002\" target=\"_blank\">Table 2</a>).</p>**<p>When using 0.5 mL vials, charging $15 for a full course does not recuperate costs for any ID regimen and charging $10 for each of the first two clinic visits does not recuperate costs for the 1-week ID regimen (see <a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd-0000982-g003\" target=\"_blank\">Figure 3</a>).</p>", "links"=>[], "tags"=>["pep", "vaccination", "regimens", "bite-victim"], "article_id"=>462816, "categories"=>["Medicine", "Infectious Diseases", "Information And Computing Sciences"], "users"=>["Katie Hampson", "Sarah Cleaveland", "Deborah Briggs"], "doi"=>"https://dx.doi.org/10.1371/journal.pntd.0000982.t005", "stats"=>{"downloads"=>1, "page_views"=>5, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Costs_of_PEP_vaccination_regimens_from_the_bite_victim_perspective_/462816", "title"=>"Costs of PEP vaccination regimens from the bite-victim perspective.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2011-03-08 00:46:56"}
  • {"files"=>["https://ndownloader.figshare.com/files/792254"], "description"=>"<p>Costs for IM administered vaccinations (the Zagreb regimen and the Essen 4-dose reduced regimen are exactly equivalent and shown in black) and ID administered vaccinations (the updated TRC regimen is shown in blue, the 4-site in red, and the 1-week in grey) per rabies death averted is plotted against clinic throughput (the number of new animal bite patients presenting for PEP vaccination each month). Shading represents 99% confidence intervals resulting from variation in patient arrival dates and the effects on vial sharing. Dashed lines highlight optimal vaccine use in high throughput clinics. Panel A is based on 0.5 mL vials and panel B on 1 mL vials. Here, we assume that vaccine is perfectly delivered without any wastage (5 complete 0.1 mL injections from a 0.5 mL vial, and 10 complete 0.1 mL injections from a 1 mL vial), but we show the reductions in efficiency assuming some wastage in <a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd.0000982.s001\" target=\"_blank\">Figure S1</a>. Note the x-axis is plotted on a log scale.</p>", "links"=>[], "tags"=>["vaccination", "rabies", "averted", "pep", "regimens"], "article_id"=>462624, "categories"=>["Medicine", "Infectious Diseases", "Information And Computing Sciences"], "users"=>["Katie Hampson", "Sarah Cleaveland", "Deborah Briggs"], "doi"=>"https://dx.doi.org/10.1371/journal.pntd.0000982.g002", "stats"=>{"downloads"=>4, "page_views"=>8, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Cost_of_vaccination_per_rabies_death_averted_for_different_PEP_regimens_according_to_clinic_throughput_/462624", "title"=>"Cost of vaccination per rabies death averted for different PEP regimens according to clinic throughput.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2011-03-08 00:43:44"}
  • {"files"=>["https://ndownloader.figshare.com/files/792506"], "description"=>"<p>Model inputs and sensitivity analyses conducted during simulations.</p>", "links"=>[], "tags"=>["inputs", "analyses", "conducted"], "article_id"=>462878, "categories"=>["Medicine", "Infectious Diseases", "Information And Computing Sciences"], "users"=>["Katie Hampson", "Sarah Cleaveland", "Deborah Briggs"], "doi"=>"https://dx.doi.org/10.1371/journal.pntd.0000982.t003", "stats"=>{"downloads"=>0, "page_views"=>3, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Model_inputs_and_sensitivity_analyses_conducted_during_simulations_/462878", "title"=>"Model inputs and sensitivity analyses conducted during simulations.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2011-03-08 00:47:58"}
  • {"files"=>["https://ndownloader.figshare.com/files/396608"], "description"=>"<div><h3>Background</h3><p>Prompt post-exposure prophylaxis (PEP) is essential in preventing the fatal onset of disease in persons exposed to rabies. Unfortunately, life-saving rabies vaccines and biologicals are often neither accessible nor affordable, particularly to the poorest sectors of society who are most at risk and upon whom the largest burden of rabies falls. Increasing accessibility, reducing costs and preventing delays in delivery of PEP should therefore be prioritized.</p><h3>Methodology/Principal Findings</h3><p>We analyzed different PEP vaccination regimens and evaluated their relative costs and benefits to bite victims and healthcare providers. We found PEP vaccination to be an extremely cost-effective intervention (from $200 to less than $60/death averted). Switching from intramuscular (IM) administration of PEP to equally efficacious intradermal (ID) regimens was shown to result in significant savings in the volume of vaccine required to treat the same number of patients, which could mitigate vaccine shortages, and would dramatically reduce the costs of implementing PEP. We present financing mechanisms that would make PEP more affordable and accessible, could help subsidize the cost for those most in need, and could even support new and existing rabies control and prevention programs.</p><h3>Conclusions/Significance</h3><p>We conclude that a universal switch to ID delivery would improve the affordability and accessibility of PEP for bite victims, leading to a likely reduction in human rabies deaths, as well as being economical for healthcare providers.</p></div>", "links"=>[], "tags"=>["cost-effective", "strategies", "rabies", "post-exposure", "vaccination", "low-income", "countries"], "article_id"=>138345, "categories"=>["Medicine", "Cancer", "Information And Computing Sciences"], "users"=>["Katie Hampson", "Sarah Cleaveland", "Deborah Briggs"], "doi"=>"https://dx.doi.org/10.1371/journal.pntd.0000982", "stats"=>{"downloads"=>2, "page_views"=>9, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/Evaluation_of_Cost_Effective_Strategies_for_Rabies_Post_Exposure_Vaccination_in_Low_Income_Countries/138345", "title"=>"Evaluation of Cost-Effective Strategies for Rabies Post-Exposure Vaccination in Low-Income Countries", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2011-03-08 02:19:05"}
  • {"files"=>["https://ndownloader.figshare.com/files/792569"], "description"=>"<p>We do not include the rarely used 8-site ID regimen <a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd.0000982-WHO5\" target=\"_blank\">[32]</a> as it was recently recommended that this be removed from the list of WHO-approved ID regimens to simplify and facilitate the use of ID PEP <a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd.0000982-WHO6\" target=\"_blank\">[33]</a>. We did not include the Thai Red Cross (TRC) regimen in analyses, because the updated TRC is always preferable requiring 4 rather than 5 clinic visits, thus entailing fewer indirect costs.</p><p>ID = intradermal, IM = intermuscular.</p><p>ACIP = Advisory Committee on Immunization Practices, USA.</p><p>*Calculated assuming 0.5 mL vials are used. **For ID regimens that use 0.4 mL or 0.8 mL of vaccine in a single hospital visit, we assume that in many cases a whole vial of vaccine will be divided between injection sites.</p>", "links"=>[], "tags"=>["rabies", "post-exposure", "vaccination"], "article_id"=>462942, "categories"=>["Medicine", "Infectious Diseases", "Information And Computing Sciences"], "users"=>["Katie Hampson", "Sarah Cleaveland", "Deborah Briggs"], "doi"=>"https://dx.doi.org/10.1371/journal.pntd.0000982.t001", "stats"=>{"downloads"=>0, "page_views"=>9, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Attributes_of_rabies_post_exposure_vaccination_regimens_/462942", "title"=>"Attributes of rabies post-exposure vaccination regimens.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2011-03-08 00:49:02"}
  • {"files"=>["https://ndownloader.figshare.com/files/792315"], "description"=>"<p>A & E) patients are charged $2.5 per injection (25% of vial costs assuming a single vial costs $10) as well as a consultation fee and materials costs (see <a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd-0000982-t004\" target=\"_blank\">Table 4</a> for the costs from the perspective of the bite victim). B & F) patients are charged $3 per injection (30% of vial costs) as well as a consultation fee and materials costs. C & G) patients are charged a flat rate of $15 for the full PEP course (the cost of 1.5 vials) as well as a consultation fee and materials costs. D & H) patients are charged a flat rate of $20 for the full PEP course ($10 for each of the first two clinic visits, equivalent to two vials) as well as a consultation fee and materials costs. A, B, C, & D) compare regimens across a range of patient throughputs (from very low to very high, 1–1000 patients per month). E, F, G & H) are a closer examination of costs in low throughput clinics (1–50 patients per month). Blue lines indicate the updated TRC ID, red lines indicate the 4-site ID and gray lines indicate the 1-week ID regimens respectively, with solid lines corresponding to 0.5 mL vials and dashed lines corresponding to 1 mL vials. The pricing strategies shown would all result in substantial losses for IM delivered PEP vaccination (not shown).</p>", "links"=>[], "tags"=>["savings", "losses", "id", "pep", "pricing"], "article_id"=>462681, "categories"=>["Medicine", "Infectious Diseases", "Information And Computing Sciences"], "users"=>["Katie Hampson", "Sarah Cleaveland", "Deborah Briggs"], "doi"=>"https://dx.doi.org/10.1371/journal.pntd.0000982.g003", "stats"=>{"downloads"=>0, "page_views"=>3, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Clinic_monthly_savings_and_losses_from_ID_administration_of_PEP_under_different_pricing_mechanisms_/462681", "title"=>"Clinic monthly savings and losses from ID administration of PEP under different pricing mechanisms.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2011-03-08 00:44:41"}
  • {"files"=>["https://ndownloader.figshare.com/files/792170"], "description"=>"<p>Framework for exploring different model inputs (detailed in <a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd-0000982-t003\" target=\"_blank\">Table 3</a>) including degree of patient compliance, types of vaccine vials and levels of vaccine waste.</p>", "links"=>[], "tags"=>["determining", "pep", "regimens"], "article_id"=>462537, "categories"=>["Medicine", "Infectious Diseases", "Information And Computing Sciences"], "users"=>["Katie Hampson", "Sarah Cleaveland", "Deborah Briggs"], "doi"=>"https://dx.doi.org/10.1371/journal.pntd.0000982.g001", "stats"=>{"downloads"=>0, "page_views"=>4, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Simulation_framework_for_determining_vaccine_use_under_different_PEP_regimens_and_model_inputs_/462537", "title"=>"Simulation framework for determining vaccine use under different PEP regimens and model inputs.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2011-03-08 00:42:17"}
  • {"files"=>["https://ndownloader.figshare.com/files/792536"], "description"=>"<p>Costs vary within and between countries. For the purpose of comparison, in our simulations we used the values that are emboldened, but absolute cost-effectiveness will depend on specific settings. Note that for analyses of costs from the patient perspective, we explore the full range of indirect costs.</p>", "links"=>[], "tags"=>["pep"], "article_id"=>462913, "categories"=>["Medicine", "Infectious Diseases", "Information And Computing Sciences"], "users"=>["Katie Hampson", "Sarah Cleaveland", "Deborah Briggs"], "doi"=>"https://dx.doi.org/10.1371/journal.pntd.0000982.t002", "stats"=>{"downloads"=>5, "page_views"=>4, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Costs_associated_with_PEP_vaccination_/462913", "title"=>"Costs associated with PEP vaccination.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2011-03-08 00:48:33"}
  • {"files"=>["https://ndownloader.figshare.com/files/792365"], "description"=>"<p>A) Additive protective efficacy of PEP (defined in <a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd-0000982-t003\" target=\"_blank\">Table 3</a>) given 50% compliance is plotted against cost-effectiveness per rabies death averted, calculated from direct medical costs (<a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd-0000982-t002\" target=\"_blank\">Table 2</a>). The different regimens are indicated as follows: reduced 4-dose Essen IM regimen in thick black, Zabreb IM in thin black, updated TRC ID in blue, 4-site ID in red and 1 week ID in gray. The dashed lines correspond to complete compliance. Here we assume use of 0.5 mL vials and clinic throughput of 100 new bite patients per month. Assuming use of 1 mL vials results are qualitatively similar but more cost-effective. B) Additive protective efficacy of PEP regimens (<a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd-0000982-t003\" target=\"_blank\">Table 3</a>) is plotted against the percentage of rabies deaths averted at high (100%, dotted lines), moderate (75%, dashed lines) and poor (50%, solid lines) levels of compliance. Thick lines correspond to regimens requiring 4 clinic visits (reduced Essen 4-dose IM, updated TRC ID) and thin lines correspond to regimens requiring 3 clinic visits (Zagreb IM, 4-site ID, 1-week ID). C) The costs of PEP regimens for bite victims according to different pricing strategies (<a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd-0000982-t005\" target=\"_blank\">Table 5</a>) are plotted against the risk of developing rabies assuming 75% additive protective efficacy for each PEP visit and assuming that patient compliance is affected by PEP costs (as described in <a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd-0000982-t003\" target=\"_blank\">Table 3</a>).</p>", "links"=>[], "tags"=>["pep", "preventing", "rabies", "cost-effectiveness"], "article_id"=>462738, "categories"=>["Medicine", "Infectious Diseases", "Information And Computing Sciences"], "users"=>["Katie Hampson", "Sarah Cleaveland", "Deborah Briggs"], "doi"=>"https://dx.doi.org/10.1371/journal.pntd.0000982.g004", "stats"=>{"downloads"=>0, "page_views"=>5, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Effects_of_compliance_on_PEP_effectiveness_in_preventing_rabies_and_cost_effectiveness_per_death_averted_/462738", "title"=>"Effects of compliance on PEP effectiveness in preventing rabies and cost-effectiveness per death averted.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2011-03-08 00:45:38"}
  • {"files"=>["https://ndownloader.figshare.com/files/792480"], "description"=>"<p>Savings are calculated from recovered costs from charging for the updated TRC PEP regimen according to the strategies described (see <a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#s3\" target=\"_blank\">methods</a> for full details) minus costs of PEP delivery (estimated from costs in <a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd-0000982-t002\" target=\"_blank\">Table 2</a>) assuming use of 1 mL vials. For all these scenarios we assume there is some wastage and therefore 8×0.1 mL injections are obtained from each 1 mL vial. Costs increase and savings decrease when 0.5 mL vials are used, as illustrated in <a href=\"http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0000982#pntd-0000982-g003\" target=\"_blank\">Figure 3</a>.</p>*<p>For the updated TRC regimen, $2.5 per injection is equivalent to $20 for the full course.</p>**<p>In parts of Tanzania the updated TRC ID regimen has been proposed for implementation.</p>", "links"=>[], "tags"=>["costs", "pep", "vaccination", "savings", "pricing"], "article_id"=>462847, "categories"=>["Medicine", "Infectious Diseases", "Information And Computing Sciences"], "users"=>["Katie Hampson", "Sarah Cleaveland", "Deborah Briggs"], "doi"=>"https://dx.doi.org/10.1371/journal.pntd.0000982.t004", "stats"=>{"downloads"=>1, "page_views"=>9, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Annual_estimated_costs_of_PEP_vaccination_per_clinic_and_savings_from_different_pricing_strategies_/462847", "title"=>"Annual estimated costs of PEP vaccination per clinic and savings from different pricing strategies.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2011-03-08 00:47:27"}

PMC Usage Stats | Further Information

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  • {"unique-ip"=>"20", "full-text"=>"20", "pdf"=>"4", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"1", "year"=>"2015", "month"=>"10"}
  • {"unique-ip"=>"21", "full-text"=>"23", "pdf"=>"8", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"3", "year"=>"2015", "month"=>"11"}
  • {"unique-ip"=>"21", "full-text"=>"22", "pdf"=>"11", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2015", "month"=>"12"}
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  • {"unique-ip"=>"16", "full-text"=>"16", "pdf"=>"3", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"2"}
  • {"unique-ip"=>"16", "full-text"=>"17", "pdf"=>"5", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"3"}
  • {"unique-ip"=>"22", "full-text"=>"25", "pdf"=>"7", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"4"}
  • {"unique-ip"=>"18", "full-text"=>"18", "pdf"=>"13", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2016", "month"=>"5"}
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  • {"unique-ip"=>"22", "full-text"=>"28", "pdf"=>"7", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"7"}
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  • {"unique-ip"=>"18", "full-text"=>"18", "pdf"=>"6", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"9", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2016", "month"=>"10"}
  • {"unique-ip"=>"33", "full-text"=>"32", "pdf"=>"8", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"23", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2016", "month"=>"11"}
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  • {"unique-ip"=>"22", "full-text"=>"17", "pdf"=>"1", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"1", "year"=>"2017", "month"=>"1"}
  • {"unique-ip"=>"17", "full-text"=>"18", "pdf"=>"2", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"2"}
  • {"unique-ip"=>"15", "full-text"=>"19", "pdf"=>"8", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"3"}
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  • {"unique-ip"=>"31", "full-text"=>"35", "pdf"=>"10", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"11"}
  • {"unique-ip"=>"29", "full-text"=>"25", "pdf"=>"3", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"4", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"12"}
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  • {"unique-ip"=>"30", "full-text"=>"29", "pdf"=>"3", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"3", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"3"}
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  • {"unique-ip"=>"27", "full-text"=>"25", "pdf"=>"4", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"5"}
  • {"unique-ip"=>"38", "full-text"=>"38", "pdf"=>"8", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"6"}
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  • {"unique-ip"=>"33", "full-text"=>"30", "pdf"=>"10", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"10"}
  • {"unique-ip"=>"25", "full-text"=>"23", "pdf"=>"6", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"4", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"9"}
  • {"unique-ip"=>"18", "full-text"=>"18", "pdf"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"2", "cited-by"=>"0", "year"=>"2018", "month"=>"11"}
  • {"unique-ip"=>"19", "full-text"=>"20", "pdf"=>"1", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"12"}
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  • {"unique-ip"=>"18", "full-text"=>"20", "pdf"=>"2", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"3"}
  • {"unique-ip"=>"22", "full-text"=>"24", "pdf"=>"6", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2019", "month"=>"4"}
  • {"unique-ip"=>"27", "full-text"=>"33", "pdf"=>"3", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"1", "year"=>"2019", "month"=>"5"}
  • {"unique-ip"=>"26", "full-text"=>"28", "pdf"=>"3", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"8"}
  • {"unique-ip"=>"23", "full-text"=>"24", "pdf"=>"7", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"9"}
  • {"unique-ip"=>"14", "full-text"=>"12", "pdf"=>"3", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"10"}
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Relative Metric

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