Cost-effectiveness of diagnostic-therapeutic strategies for paediatric visceral leishmaniasis in Morocco

A Systematic Review on Economic Evaluation Studies of Diagnostic and Therapeutic Interventions in the Middle East and North Africa

INTRODUCTION

Due to the increase in healthcare budget constraint, economic evaluation (EE) evidence is increasingly required to inform resource allocation decisions. This study aimed to systematically review quantity, characteristics, and quality of full EE studies on diagnostic and therapeutic interventions conducted in 26 Middle East and North Africa (MENA) countries.

METHODS

PubMed and Scopus databases were comprehensively searched to identify the published EE studies in the MENA region. The quality of reviewed studies was evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

RESULTS

The search identified 69 studies. The cost-utility approach was adopted in 49 studies (71 %). More than half (38 studies; 55 %) were conducted in Iran and Turkey. Sixteen countries (62 %) did not have any EE studies. The most frequently analyzed therapeutic areas were infectious diseases (19 studies; 28 %), cardiovascular diseases (11 studies; 16 %), and malignancies (10 studies; 14 %). Ten studies (14 %), 46 (67 %), 12 (17 %), and 1 study (1 %) were classified as excellent, high, moderate, and poor quality, respectively. The mean of items reported was 85.10 % (standard deviation 13.32 %). Characterizing heterogeneity, measurement of effectiveness, time horizon, and discount rate were missed in 21 (60 %), 22 (32 %), 20 (29 %) and 15 (25 %) studies, respectively. Data on effectiveness and utility relied primarily on studies conducted outside the region.

CONCLUSIONS

The quantity of EE studies in the MENA region remains low; however, overall quality is high to excellent. The availability of local data, capacity building, and national guidelines are vital to improve both the quantity and quality of EE studies in the region.

Cost-effectiveness analysis of diagnostic-therapeutic strategies for visceral leishmaniasis in Brazil

INTRODUCTION

Visceral leishmaniasis (VL) is fatal if not diagnosed and treated. This study aimed to estimate the cost-effectiveness of diagnostic-therapeutic alternatives for VL in Brazil.

METHODS

A decision model estimated the life expectancy and costs of six diagnostic-therapeutic strategies.

RESULTS

IT LEISH + liposomal amphotericin B emerged the best option, presenting lower costs and higher effectiveness. DAT-LPC + liposomal amphotericin B showed an incremental cost-effectiveness ratio of US$ 326.31 per life year.

CONCLUSIONS

These findings indicate the feasibility of incorporating DAT and designating liposomal amphotericin B as the first-line drug for VL in Brazil.

Model-based economic evaluations of diagnostic point of care tests were rarely fit for purpose

OBJECTIVES

Linked evidence models are recommended to predict health benefits and cost-effectiveness of diagnostic tests. We considered how published models accounted for changes in patient pathways that occur with point of care tests (POCTs) and their impact on patient health and costs.

STUDY DESIGN AND SETTING

Model-based evaluations of diagnostic POCTs published from 2004 to 2017 were identified from searching six databases. For each model, we assessed the outcomes considered, and whether reduced time to diagnosis and increased access to testing affected patient health and costs.

RESULTS

Seventy-four model-based evaluations were included: 95% incorporated evidence on test accuracy, but 34% only assessed intermediate outcomes such as rates of correct diagnosis. Of 54 models where POCTs reduced testing time, 39% addressed the economic and 37% addressed the health benefits of faster diagnosis. No model considered differences in access to tests.

CONCLUSION

Many models fail to capture the effects of POCTs in increasing access, advancing speed of diagnosis and treatment, and reducing anxiety and the associated costs. Many only consider the impact of testing from changes in accuracy. Ensuring models incorporate changes in patient pathways from faster and more accessible testing will lead to economic evaluations that better reflect the impact of POCTs.

Rapid diagnosis of parasitic diseases: current scenario and future needs

BACKGROUND

Parasitic diseases are one of the world's most devastating and prevalent infections, causing millions of morbidities and mortalities annually. In the past, many of these infections have been linked predominantly to tropical or subtropical areas. Nowadays, however, climatic and vector ecology changes, a significant increase in international travel, armed conflicts, and migration of humans and animals have influenced the transmission of some parasitic diseases from 'book pages' to reality in developed countries. It has also been noted that many patients who have never travelled to endemic areas suffer from blood-borne infections caused by protozoa. In the light of existing knowledge, this new trend can be explained by the fact that in the process of migration a large number of asymptomatic carriers become a part of the blood bank donor and transplant donor populations. Accurate and rapid diagnosis represents the crucial weapon in the fight against parasitic infections.

AIMS

To review old and new approaches for rapid diagnosis of parasitic infections.

SOURCES

Data for this review were obtained through searches of PubMed using combinations of the following terms: parasitological diagnostics, microscopy, lateral flow assays, immunochromatographic assays, multiplex-PCR, and transplantation.

CONTENT

In this review, we provide a brief account of the advantages and limitations of rapid methods for diagnosis of parasitic diseases and focus our attention on current and future research in this area. The approximate costs associated with the use of different techniques and their applicability in endemic and non-endemic areas are also discussed.

IMPLICATIONS

Microscopy remains the cornerstone of parasitological diagnostics, especially in the field and low-resource settings, and provides epidemiological assessment of parasite burden. However, increased use and availability of point-of-care tests and molecular assays in modern era allow more rapid and accurate diagnoses and increased sensitivity in the identification of parasitic infections.

Validation of rK39 immunochromatographic test and direct agglutination test for the diagnosis of Mediterranean visceral leishmaniasis in Spain

Background

Visceral leishmaniasis (VL), the most severe form of leishmaniasis, is endemic in Europe with Mediterranean countries reporting endemic status alongside a worrying northward spread. Serological diagnosis, including immunochromatographic test based on the recombinant antigen rK39 (rK39-ICT) and a direct agglutination test (DAT) based on the whole parasite antigen, have been validated in regions with high VL burden, such as eastern Africa and the Indian subcontinent. To date, no studies using a large set of patients have performed an assessment of both methods within Europe.

Methodology/Principal findings

We selected a range of clinical serum samples from patients with confirmed VL (including HIV co-infection), Chagas disease, malaria, other parasitic infections and negative samples (n = 743; years 2009–2015) to test the performance of rK39-ICT rapid test (Kalazar Detect Rapid Test; InBios International, Inc., USA) and DAT (ITM-DAT/VLG; Institute of Tropical Medicine Antwerp, Belgium). An in-house immunofluorescence antibody test (IFAT), was included for comparison. Estimated sensitivities for rK39-ICT and DAT in HIV-negative VL patients were 83.1% [75.1–91.2] and 84.2% [76.3–92.1], respectively. Sensitivity was reduced to 67.3% [52.7–82.0] for rK39 and increased to 91.3% [82.1–100.0] for DAT in HIV/VL co-infected patients. The in-house IFAT was more sensitive in HIV-negative VL patients, 84.2% [76.3–92.1] than in HIV/VL patients, 79.4% [73.3–96.2]. DAT gave 32 false positives in sera from HIV-negative VL suspects, compared to 0 and 2 for rK39 and IFAT, respectively, but correctly detected more HIV/VL patients (42/46) than rK39 (31/46) and IFAT (39/46).

Conclusions/Significance

Though rK39-ICT and DAT exhibited acceptable sensitivity and specificity a combination with other tests is required for highly sensitive diagnosis of VL cases in Spain. Important variation in the performance of the tests were seen in patients co-infected with HIV or with other parasitic infections. This study can help inform the choice of serological test to be used when screening or diagnosing VL in a European Mediterranean setting.

Visceral leishmaniasis is the most severe form of leishmaniasis, a disease transmitted through the bite of an infected sandfly. Although the biggest burden of leishmaniasis is in eastern Africa and the Indian subcontinent, the disease is also endemic in parts of Europe. Previous studies have looked at performance of diagnostic methods, but not in great detail on samples derived from a European setting. Using a large set of samples from a national reference laboratory in Madrid, Spain, we assessed a leishmaniasis rapid test and a direct agglutination test for serological diagnosis of visceral leishmaniasis in Europe. Both tests were effective at diagnosing VL, but important differences were seen when testing patients co-infected with HIV or with other parasitic infections. This study can help inform which diagnostic tests are suitable for use in a European Mediterranean setting.