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Hounsome N, Yirgu R, Middleton J, Cassell JA, Fekadu A, Davey G. Cost-effectiveness of mass drug administration for control of scabies in Ethiopia: a decision-analytic model. FRONTIERS IN HEALTH SERVICES 2024; 4:1279762. [PMID: 39359345 PMCID: PMC11445614 DOI: 10.3389/frhs.2024.1279762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/04/2024] [Indexed: 10/04/2024]
Abstract
Background The strategies to control scabies in highly endemic populations include individual case/household management and mass drug administration (MDA). We used a decision-analytic model to compare ivermectin-based MDA and individual case/household management (referred to as "usual care") for control of scabies in Ethiopia at different prevalence thresholds for commencing MDA. Methods A decision-analytic model was based on a repeated population survey conducted in Northern Ethiopia in 2018-2020, which aimed to evaluate the secondary impact of single-dose ivermectin MDA for the control of onchocerciasis on scabies prevalence. The model estimates the number of scabies cases and costs of two treatment strategies (MDA and usual care) based on their effectiveness, population size, scabies prevalence, compliance with MDA, medication cost, and other parameters. Results In the base-case analysis with a population of 100,000 and scabies prevalence of 15%, the MDA strategy was both more effective and less costly than usual care. The probability of MDA being cost-effective at the current cost-effectiveness threshold (equivalent to the cost of usual care) was 85%. One-way sensitivity analyses showed that the MDA strategy remained dominant (less costly and more effective) in 22 out of 26 scenarios. MDA was not cost-effective at scabies prevalence <10%, MDA effectiveness <85% and population size <5,000. An increase in the cost of ivermectin from 0 (donated) to 0.54 US$/dose resulted in a decrease in the probability of MDA being cost-effective from 85% to 17%. At 0.25 US$/dose, the MDA strategy was no longer cost-effective. Conclusions The model provides robust estimates of the costs and outcomes of MDA and usual care and can be used by decision-makers for planning and implementing scabies control programmes. Results of our analysis suggest that single-dose ivermectin MDA is cost-effective in scabies control and can be initiated at a scabies prevalence >10%.
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Affiliation(s)
- Natalia Hounsome
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Robel Yirgu
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
| | - Jo Middleton
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Jackie A. Cassell
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Abebaw Fekadu
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, Addis Ababa, Ethiopia
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gail Davey
- Brighton and Sussex Centre for Global Health Research, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
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Hamill L, Trotignon G, MacKenzie C, Hill B, Pavluck A, Yumba D, Isiyaku S, William A, Nyior A, Igbe M, Anyaike C, Akilah J, Agyemang D, Marfo B, Downs P, Jones I. Navigating the way to onchocerciasis elimination: the feasibility and affordability of Onchocerciasis Elimination Mapping. Int Health 2022; 14:i17-i23. [PMID: 35169850 PMCID: PMC8986348 DOI: 10.1093/inthealth/ihab083] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/02/2021] [Accepted: 02/09/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Onchocerciasis is targeted for elimination of transmission by 2030 in at least 21 countries. To achieve this, recent and accurate data on the extent and intensity of onchocerciasis transmission are required. This will include mapping areas previously unassessed, or remapping of areas that were last visited as part surveys aiming to prevent blindness, not assess transmission in totality. There is near universal acceptance of the need to carry out these mapping reassessments, to achieve equitable and lasting elimination of onchocerciasis transmission. However, there is no consensus on how to conduct onchocerciasis elimination mapping (OEM), and little published data to inform policymakers and programme managers, including on cost. METHODS Here, we summarise the methods and cost implications of conducting pilot OEM surveys in Ghana and Nigeria in 2018. We have included a breakdown of costs incurred overall, per person and per implementation unit in each country, as well as detailed analysis of the cost categories and the main cost drivers. RESULTS The procurement and logistics of diagnostics accounted for more than one-third of the total cost, a significant cost driver. CONCLUSIONS This information will be valuable to policymakers and donors as they seek to prioritise onchocerciasis elimination and plan to complete OEM.
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Affiliation(s)
| | | | - Charles MacKenzie
- Coalition for Operational Research on Neglected Tropical Diseases, Task Force for Global Health, 330 West Ponce de Leon Avenue, Decatur, GA, 30030, USA
| | - Becks Hill
- Sightsavers, 35 Perrymount Road, Haywards Heath, England, UK RH16 3BZ
| | - Alex Pavluck
- Sightsavers, 35 Perrymount Road, Haywards Heath, England, UK RH16 3BZ
| | - Dyesse Yumba
- Expanded Special Programme for Elimination of NTDs, World Health Organization Regional Office for Africa, Cité du Djoué, P.O. Box 06 Brazzaville, Republic of Congo
| | - Sunday Isiyaku
- Sightsavers, Golf Course Road, City Centre 800283, Kaduna, Nigeria
| | - Adamani William
- Sightsavers, Golf Course Road, City Centre 800283, Kaduna, Nigeria
| | - Audrey Nyior
- Onchocerciasis Elimination Programme of Nigeria, Federal Ministry of Health, New Federal Secretariat Complex, Ahmadu Bello Way, Phase III, Abuja, Nigeria
| | - Michael Igbe
- Onchocerciasis Elimination Programme of Nigeria, Federal Ministry of Health, New Federal Secretariat Complex, Ahmadu Bello Way, Phase III, Abuja, Nigeria
| | - Chukwuma Anyaike
- Onchocerciasis Elimination Programme of Nigeria, Federal Ministry of Health, New Federal Secretariat Complex, Ahmadu Bello Way, Phase III, Abuja, Nigeria
| | - Joel Akilah
- Onchocerciasis Elimination Programme of Nigeria, Federal Ministry of Health, New Federal Secretariat Complex, Ahmadu Bello Way, Phase III, Abuja, Nigeria
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Albert H, Sartorius B, Bessell PR, de Souza DK, Rupani S, Gonzalez K, Kayembe S, Ndung’u J, Pullan R, Makana DP, de Almeida MCC, Uvon NA. Developing Strategies for Onchocerciasis Elimination Mapping and Surveillance Through The Diagnostic Network Optimization Approach. FRONTIERS IN TROPICAL DISEASES 2021. [DOI: 10.3389/fitd.2021.707752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BackgroundOnchocerciasis (river blindness) is a filarial disease targeted for elimination of transmission. However, challenges exist to the implementation of effective diagnostic and surveillance strategies at various stages of elimination programs. To address these challenges, we used a network data analytics approach to identify optimal diagnostic scenarios for onchocerciasis elimination mapping (OEM).MethodsThe diagnostic network optimization (DNO) method was used to model the implementation of the old Ov16 rapid diagnostic test (RDT) and of new RDTs in development for OEM under different testing strategy scenarios with varying testing locations, test performance and disease prevalence. Environmental suitability scores (ESS) based on machine learning algorithms were developed to identify areas at risk of transmission and used to select sites for OEM in Bandundu region in the Democratic Republic of Congo (DRC) and Uige province in Angola. Test sensitivity and specificity ranges were obtained from the literature for the existing RDT, and from characteristics defined in the target product profile for the new RDTs. Sourcing and transportation policies were defined, and costing information was obtained from onchocerciasis programs. Various scenarios were created to test various state configurations. The actual demand scenarios represented the disease prevalence at IUs according to the ESS, while the counterfactual scenarios (conducted only in the DRC) are based on adapted prevalence estimates to generate prevalence close to the statistical decision thresholds (5% and 2%), to account for variability in field observations. The number of correctly classified implementation units (IUs) per scenario were estimated and key cost drivers were identified.ResultsIn both Bandundu and Uige, the sites selected based on ESS had high predicted onchocerciasis prevalence >10%. Thus, in the actual demand scenarios in both Bandundu and Uige, the old Ov16 RDT correctly classified all 13 and 11 IUs, respectively, as requiring CDTi. In the counterfactual scenarios in Bandundu, the new RDTs with higher specificity correctly classified IUs more cost effectively. The new RDT with highest specificity (99.8%) correctly classified all 13 IUs. However, very high specificity (e.g., 99.8%) when coupled with imperfect sensitivity, can result in many false negative results (missing decisions to start MDA) at the 5% statistical decision threshold (the decision rule to start MDA). This effect can be negated by reducing the statistical decision threshold to 2%. Across all scenarios, the need for second stage sampling significantly drove program costs upwards. The best performing testing strategies with new RDTs were more expensive than testing with existing tests due to need for second stage sampling, but this was offset by the cost of incorrect classification of IUs.ConclusionThe new RDTs modelled added most value in areas with variable disease prevalence, with most benefit in IUs that are near the statistical decision thresholds. Based on the evaluations in this study, DNO could be used to guide the development of new RDTs based on defined sensitivities and specificities. While test sensitivity is a minor driver of whether an IU is identified as positive, higher specificities are essential. Further, these models could be used to explore the development and optimization of new tools for other neglected tropical diseases.
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Batsa Debrah L, Klarmann-Schulz U, Osei-Mensah J, Dubben B, Fischer K, Mubarik Y, Ayisi-Boateng NK, Ricchiuto A, Fimmers R, Konadu P, Nadal J, Gruetzmacher B, Weil G, Kazura JW, King CL, Debrah AY, Hoerauf A. Comparison of Repeated Doses of Ivermectin Versus Ivermectin Plus Albendazole for the Treatment of Onchocerciasis: A Randomized, Open-label, Clinical Trial. Clin Infect Dis 2021; 71:933-943. [PMID: 31536624 PMCID: PMC7428389 DOI: 10.1093/cid/ciz889] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 09/13/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Improved treatment for onchocerciasis is needed to accelerate onchocerciasis elimination in Africa. Aiming to better exploit registered drugs, this study was undertaken to determine whether annual or semiannual treatment with ivermectin (IVM; 200 µg/kg) plus albendazole (ALB; 800 mg single dose) is superior to IVM alone. METHODS This trial was performed in Ghana and included 272 participants with microfilariae (MF), who were randomly assigned to 4 treatment arms: (1) IVM annually at 0, 12, and 24 months; (2) IVM semiannually at 0, 6, 12, 18, and 24 months; (3) IVM+ALB annually; or (4) IVM+ALB semiannually. Microfiladermia was determined pretreatment and at 6, 18, and 36 months. The primary outcome was the proportion of fertile and viable female worms in onchocercomata excised at 36 months. RESULTS Posttreatment nodule histology showed that 15/135 (11.1%), 22/155 (14.2%), 35/154 (22.7%), and 20/125 (16.0%) living female worms had normal embryogenesis in the IVM annual, IVM semiannual, IVM+ALB annual, and IVM+ALB semiannual groups, respectively (P = .1229). Proportions of dead worms also did not differ between the 4 groups (P = .9198). Proportions of patients without MF at 36 months (1 year after the last treatment) were 35/56 (63%) after annual IVM, 42/59 (71%) after semiannual IVM, 39/64 (61%) after annual IVM+ALB, and 43/53 (81%) after semiannual IVM+ALB. CONCLUSIONS The combination treatment of IVM plus ALB was no better than IVM alone for sterilizing, killing adult worms, or achieving sustained MF clearance. However, semiannual treatment was superior to annual treatment for achieving sustained clearance of Onchocerca volvulus MF from the skin (P = .024). CLINICAL TRIALS REGISTRATION ISRCTN50035143.
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Affiliation(s)
- Linda Batsa Debrah
- Kumasi Center for Collaborative Research, Kumasi, Ghana.,Department of Clinical Microbiology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Ute Klarmann-Schulz
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Germany.,German Center for Infection Research, Bonn-Cologne site, Germany.,Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Germany
| | | | - Bettina Dubben
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Germany
| | - Kerstin Fischer
- Infectious Diseases Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Yusif Mubarik
- Kumasi Center for Collaborative Research, Kumasi, Ghana
| | | | - Arcangelo Ricchiuto
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Germany
| | - Rolf Fimmers
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Germany
| | - Peter Konadu
- School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Jennifer Nadal
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Germany
| | - Barbara Gruetzmacher
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Germany
| | - Gary Weil
- Infectious Diseases Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - James W Kazura
- Center for Global Health and Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Christopher L King
- Center for Global Health and Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Veterans Affairs Medical Center, Cleveland, Ohio
| | - Alexander Y Debrah
- Kumasi Center for Collaborative Research, Kumasi, Ghana.,Faculty for Allied Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Achim Hoerauf
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Germany.,German Center for Infection Research, Bonn-Cologne site, Germany
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Shey RA, Ghogomu SM, Shintouo CM, Nkemngo FN, Nebangwa DN, Esoh K, Yaah NE, Manka’aFri M, Nguve JE, Ngwese RA, Njume FN, Bertha FA, Ayong L, Njemini R, Vanhamme L, Souopgui J. Computational Design and Preliminary Serological Analysis of a Novel Multi-Epitope Vaccine Candidate against Onchocerciasis and Related Filarial Diseases. Pathogens 2021; 10:99. [PMID: 33494344 PMCID: PMC7912539 DOI: 10.3390/pathogens10020099] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 11/16/2022] Open
Abstract
: Onchocerciasis is a skin and eye disease that exerts a heavy socio-economic burden, particularly in sub-Saharan Africa, a region which harbours greater than 96% of either infected or at-risk populations. The elimination plan for the disease is currently challenged by many factors including amongst others; the potential emergence of resistance to the main chemotherapeutic agent, ivermectin (IVM). Novel tools, including preventative and therapeutic vaccines, could provide additional impetus to the disease elimination tool portfolio. Several observations in both humans and animals have provided evidence for the development of both natural and artificial acquired immunity. In this study, immuno-informatics tools were applied to design a filarial-conserved multi-epitope subunit vaccine candidate, (designated Ov-DKR-2) consisting of B-and T-lymphocyte epitopes of eight immunogenic antigens previously assessed in pre-clinical studies. The high-percentage conservation of the selected proteins and epitopes predicted in related nematode parasitic species hints that the generated chimera may be instrumental for cross-protection. Bioinformatics analyses were employed for the prediction, refinement, and validation of the 3D structure of the Ov-DKR-2 chimera. In-silico immune simulation projected significantly high levels of IgG1, T-helper, T-cytotoxic cells, INF-γ, and IL-2 responses. Preliminary immunological analyses revealed that the multi-epitope vaccine candidate reacted with antibodies in sera from both onchocerciasis-infected individuals, endemic normals as well as loiasis-infected persons but not with the control sera from European individuals. These results support the premise for further characterisation of the engineered protein as a vaccine candidate for onchocerciasis.
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Affiliation(s)
- Robert Adamu Shey
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
- Department of Molecular Biology, Institute of Biology and Molecular Medicine, IBMM, Université Libre de Bruxelles, Gosselies Campus, 6040 Gosselies, Belgium;
| | - Stephen Mbigha Ghogomu
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
| | - Cabirou Mounchili Shintouo
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
- Frailty in Ageing Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, B-1090 Brussels, Belgium;
- Department of Gerontology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, B-1090 Brussels, Belgium
| | - Francis Nongley Nkemngo
- Department of Microbiology and Parasitology, Faculty of Science, University of Buea, Buea 99999, Cameroon;
- Centre for Research in Infectious Diseases (CRID), Department of Parasitology and Medical Entomology, Yaounde BP 13591, Cameroon
| | - Derrick Neba Nebangwa
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
| | - Kevin Esoh
- Division of Human Genetics, Health Sciences Campus, Department of Pathology, University of Cape Town, Anzio Rd, Observatory, Cape Town 7925, South Africa;
| | - Ntang Emmaculate Yaah
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
| | - Muyanui Manka’aFri
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
| | - Joel Ebai Nguve
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
| | - Roland Akwelle Ngwese
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
| | - Ferdinand Ngale Njume
- Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea 99999, Cameroon; (R.A.S.); (S.M.G.); (C.M.S.); (D.N.N.); (N.E.Y.); (M.M.); (J.E.N.); (R.A.N.); (F.N.N.)
- Department of Molecular Biology, Institute of Biology and Molecular Medicine, IBMM, Université Libre de Bruxelles, Gosselies Campus, 6040 Gosselies, Belgium;
| | - Fru Asa Bertha
- Department of Public Health and Hygiene, Faculty of Health Science, University of Buea, Buea 99999, Cameroon;
| | - Lawrence Ayong
- Malaria Research Unit, Centre Pasteur Cameroon, Yaoundé Rue 2005, Cameroon;
| | - Rose Njemini
- Frailty in Ageing Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, B-1090 Brussels, Belgium;
- Department of Gerontology, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Laarbeeklaan 103, B-1090 Brussels, Belgium
| | - Luc Vanhamme
- Department of Molecular Biology, Institute of Biology and Molecular Medicine, IBMM, Université Libre de Bruxelles, Gosselies Campus, 6040 Gosselies, Belgium;
| | - Jacob Souopgui
- Department of Molecular Biology, Institute of Biology and Molecular Medicine, IBMM, Université Libre de Bruxelles, Gosselies Campus, 6040 Gosselies, Belgium;
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Salari P, Fürst T, Knopp S, Rollinson D, Kabole F, Khamis MI, Omar MA, Bacon O, Ali SM, Utzinger J, Tediosi F. Financial Costs of the Zanzibar Elimination of Schistosomiasis Transmission Project. Am J Trop Med Hyg 2020; 103:2260-2267. [PMID: 32996446 PMCID: PMC7695112 DOI: 10.4269/ajtmh.20-0252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
We estimated the financial costs of different interventions against urogenital schistosomiasis, implemented by the Zanzibar Elimination of Schistosomiasis Transmission (ZEST) project, on Pemba and Unguja islands, Tanzania. We used available data on project activities, resources used, and costs reported in the accounting information systems of ZEST partners. The costs were estimated for all the activities related to snail control, behavior change interventions, the impact assessment surveys, and management of the whole program. Costs are presented in US$ for the full duration of the ZEST project from 2011/2012 to 2017. The total financial costs of implementing snail control activities over 5 years, excluding the costs for donated Bayluscide, were US$55,796 on Pemba and US$73,581 on Unguja, mainly driven by personnel costs. The total financial costs of implementing behavior change activities were US$109,165 on Pemba and US$155,828 on Unguja, with costs for personnel accounting for 47% on Pemba and 69% on Unguja. Costs of implementing biannual mass drug administration refer to the estimated 2.4 million treatments provided on Pemba over 4 years (2013–2016), and do not include the costs of donated praziquantel. The total cost per provided treatment was, on average, US$0.21. This study showed the value of exploiting administrative data to estimate costs of major global health interventions. It also provides an evidence base for financial costs and main cost drivers of implementing multiple combinations of intervention sets that inform decisions regarding the feasibility and affordability of implementing schistosomiasis control and elimination strategies.
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Affiliation(s)
- Paola Salari
- University of Basel, Basel, Switzerland.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Thomas Fürst
- University of Basel, Basel, Switzerland.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Stefanie Knopp
- University of Basel, Basel, Switzerland.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | - Fatma Kabole
- Neglected Diseases Program, Zanzibar Ministry of Health, Zanzibar, Tanzania
| | - Mohammed I Khamis
- Neglected Diseases Program, Zanzibar Ministry of Health, Zanzibar, Tanzania
| | - Mussa A Omar
- Public Health Laboratory-Ivo de Carneri, Chake Chake, Tanzania
| | | | - Said M Ali
- Public Health Laboratory-Ivo de Carneri, Chake Chake, Tanzania
| | - Jürg Utzinger
- University of Basel, Basel, Switzerland.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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7
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Cirera L, Galatas B, Alonso S, Paaijmans K, Mamuquele M, Martí-Soler H, Guinovart C, Munguambe H, Luis F, Nhantumbo H, Montañà J, Bassat Q, Candrinho B, Rabinovich R, Macete E, Aide P, Alonso P, Saúte F, Sicuri E. Moving towards malaria elimination in southern Mozambique: Cost and cost-effectiveness of mass drug administration combined with intensified malaria control. PLoS One 2020; 15:e0235631. [PMID: 32628741 PMCID: PMC7337313 DOI: 10.1371/journal.pone.0235631] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/08/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND As new combinations of interventions aiming at interrupting malaria transmission are under evaluation, understanding the associated economic costs and benefits is critical for decision-making. This study assessed the economic cost and cost-effectiveness of the Magude project, a malaria elimination initiative implemented in a district in southern Mozambique (i.e. Magude) between August 2015-June 2018. This project piloted a combination of two mass drug administration (MDA) rounds per year for two consecutive years, annual rounds of universal indoor residual spraying (IRS) and a strengthened surveillance and response system on the back of universal long-lasting insecticide treated net (LLIN) coverage and routine case management implemented by the National Malaria Control Program (NMCP). Although local transmission was not interrupted, the project achieved large reductions in the burden of malaria in the target district. METHODS We collected weekly economic data, estimated costs from the project implementer perspective and assessed the incremental cost-effectiveness ratio (ICER) associated with the Magude project as compared to routine malaria control activities, the counterfactual. We estimated disability-adjusted life years (DALYs) for malaria cases and deaths and assessed the variation of the ICER over time to capture the marginal costs and effectiveness associated with subsequent phases of project implementation. We used deterministic and probabilistic sensitivity analyses to account for uncertainty and built an alternative scenario by assuming the implementation of the interventions from a governmental perspective. Economic costs are provided in constant US$2015. RESULTS After three years, the Magude project averted a total of 3,171 DALYs at an incremental cost of $2.89 million and an average yearly cost of $20.7 per targeted person. At an average cost of $19.4 per person treated per MDA round, the social mobilization and distribution of door-to-door MDA contributed to 53% of overall resources employed, with personnel and logistics being the main cost drivers. The ICER improved over time as a result of decreasing costs and improved effectiveness. The overall ICER was $987 (CI95% 968-1,006) per DALY averted, which is below the standard cost-effectiveness (CE) threshold of $1,404/DALY averted, three times the gross domestic product (GDP) per capita of Mozambique, but above the threshold of interventions considered highly cost-effective (one time the GDP per capita or $468/DALY averted) and above the recently suggested thresholds based on the health opportunity cost ($537 purchasing power parity/ DALY averted). A significantly lower ICER was obtained in the implementation scenario from a governmental perspective ($441/DALY averted). CONCLUSION Despite the initial high costs and volume of resources associated with its implementation, MDA in combination with other existing malaria control interventions, can be a cost-effective strategy to drastically reduce transmission in areas of low to moderate transmission in sub-Saharan Africa. However, further studies are needed to understand the capacity of the health system and financial affordability to scale up such strategies at regional or national level.
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Affiliation(s)
- Laia Cirera
- ISGlobal, Hospital Clínic -Universitat de Barcelona, Barcelona, Spain
| | - Beatriz Galatas
- ISGlobal, Hospital Clínic -Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Sergi Alonso
- Centre for Primary Care and Public Health, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom
| | - Krijn Paaijmans
- ISGlobal, Hospital Clínic -Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
- Center for Evolution and Medicine & The Biodesign Center for Immunotherapy, Vaccines and Virotherapy, School of Life Sciences, Arizona State University, Tempe, Arizona, United States of America
| | - Miler Mamuquele
- Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | | | | | | | - Fabião Luis
- Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Hoticha Nhantumbo
- Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Júlia Montañà
- ISGlobal, Hospital Clínic -Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Quique Bassat
- ISGlobal, Hospital Clínic -Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain
- ICREA, Barcelona, Spain
| | - Baltazar Candrinho
- National Malaria Control Program, Ministry of Health, Maputo, Mozambique
| | - Regina Rabinovich
- ISGlobal, Hospital Clínic -Universitat de Barcelona, Barcelona, Spain
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Eusebio Macete
- Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
- National Institute of Health, Ministry of Health, Maputo, Mozambique
| | - Pedro Aide
- Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
- National Institute of Health, Ministry of Health, Maputo, Mozambique
| | - Pedro Alonso
- ISGlobal, Hospital Clínic -Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Francisco Saúte
- Centro de Investigação em Saúde da Manhiça (CISM), Manhiça, Mozambique
| | - Elisa Sicuri
- ISGlobal, Hospital Clínic -Universitat de Barcelona, Barcelona, Spain
- Department of Infectious Disease Epidemiology, Health Economics Group, School of Public Health, Imperial College London, London, United Kingdom
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8
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Turner HC, Toor J, Bettis AA, Hopkins AD, Kyaw SS, Onwujekwe O, Thwaites GE, Lubell Y, Fitzpatrick C. Valuing the Unpaid Contribution of Community Health Volunteers to Mass Drug Administration Programs. Clin Infect Dis 2020; 68:1588-1595. [PMID: 30169566 PMCID: PMC6481994 DOI: 10.1093/cid/ciy741] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/25/2018] [Indexed: 12/04/2022] Open
Abstract
Community health volunteers (CHVs) are being used within a growing number of healthcare interventions, and they have become a cornerstone for the delivery of mass drug administration within many neglected tropical disease control programs. However, a greater understanding of the methods used to value the unpaid time CHVs contribute to healthcare programs is needed. We outline the two main approaches used to value CHVs’ unpaid time (the opportunity cost and the replacement cost approaches). We found that for mass drug administration programs the estimates of the economic costs relating to the CHVs’ unpaid time can be significant, with the averages of the different studies varying between US$0.05 and $0.16 per treatment. We estimated that the time donated by CHVs’ to the African Programme for Onchocerciasis Control alone would be valued between US$60 and $90 million. There is a need for greater transparency and consistency in the methods used to value CHVs’ unpaid time.
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Affiliation(s)
- Hugo C Turner
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford
| | - Jaspreet Toor
- London Centre for Neglected Tropical Disease Research, School of Public Health, Faculty of Medicine, St Marys Campus, Imperial College London.,Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine, St Marys Campus, Imperial College London
| | - Alison A Bettis
- London Centre for Neglected Tropical Disease Research, School of Public Health, Faculty of Medicine, St Marys Campus, Imperial College London.,Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine, St Marys Campus, Imperial College London
| | | | - Shwe Sin Kyaw
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Obinna Onwujekwe
- Department of Health Administration and Management, University of Nigeria Enugu Campus.,Health Policy Research Group, Department of Pharmacology and Therapeutics, College of Medicine, University of Nigeria Enugu Campus, Enugu, Nigeria
| | - Guy E Thwaites
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford
| | - Yoel Lubell
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Christopher Fitzpatrick
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
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9
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Turner HC, Toor J, Hollingsworth TD, Anderson RM. Economic Evaluations of Mass Drug Administration: The Importance of Economies of Scale and Scope. Clin Infect Dis 2019; 66:1298-1303. [PMID: 29126255 PMCID: PMC5888956 DOI: 10.1093/cid/cix1001] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 11/07/2017] [Indexed: 12/12/2022] Open
Abstract
It is recognized that changing the current approaches for the control of the neglected tropical diseases will be needed to reach the World Health Organization’s (WHO) 2020 goals. Consequently, it is important that economic evaluations of the alternative approaches are conducted. A vital component of such evaluations is the issue of how the intervention’s costs should be incorporated. We discuss this issue—focusing on mass drug administration. We argue that the common approach of assuming an intervention’s cost per treatment is constant, regardless of the number of individuals treated, is a misleading way to consider the delivery costs of mass drug administration due to the occurrence of economies/diseconomies of scale and scope. Greater care and consideration are required when the costs are incorporated into such analyses. Without this, these economic evaluations could potentially lead to incorrect policy recommendations.
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Affiliation(s)
- Hugo C Turner
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford United Kingdom
- Correspondence: H. Turner, Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam ()
| | - Jaspreet Toor
- London Centre for Neglected Tropical Disease Research, University of Oxford, United Kingdom
- Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine, St Mary’s Campus, Imperial College London, Norfolk Place, University of Oxford, United Kingdom
| | - T Déirdre Hollingsworth
- Mathematics Institute, University of Oxford, United Kingdom
- School of Life Sciences, University of Warwick, Coventry, University of Oxford, United Kingdom
- Big Data Institute, University of Oxford, United Kingdom
| | - Roy M Anderson
- London Centre for Neglected Tropical Disease Research, University of Oxford, United Kingdom
- Department of Infectious Disease Epidemiology, School of Public Health, Faculty of Medicine, St Mary’s Campus, Imperial College London, Norfolk Place, University of Oxford, United Kingdom
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10
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Sharma S, Smith ME, Reimer J, O'Brien DB, Brissau JM, Donahue MC, Carter CE, Michael E. Economic performance and cost-effectiveness of using a DEC-salt social enterprise for eliminating the major neglected tropical disease, lymphatic filariasis. PLoS Negl Trop Dis 2019; 13:e0007094. [PMID: 31260444 PMCID: PMC6625731 DOI: 10.1371/journal.pntd.0007094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 07/12/2019] [Accepted: 06/06/2019] [Indexed: 01/01/2023] Open
Abstract
Background Salt fortified with the drug, diethylcarbamazine (DEC), and introduced into a competitive market has the potential to overcome the obstacles associated with tablet-based Lymphatic Filariasis (LF) elimination programs. Questions remain, however, regarding the economic viability, production capacity, and effectiveness of this strategy as a sustainable means to bring about LF elimination in resource poor settings. Methodology and principal findings We evaluated the performance and effectiveness of a novel social enterprise-based approach developed and tested in Léogâne, Haiti, as a strategy to sustainably and cost-efficiently distribute DEC-medicated salt into a competitive market at quantities sufficient to bring about the elimination of LF. We undertook a cost-revenue analysis to evaluate the production capability and financial feasibility of the developed DEC salt social enterprise, and a modeling study centered on applying a dynamic mathematical model localized to reflect local LF transmission dynamics to evaluate the cost-effectiveness of using this intervention versus standard annual Mass Drug Administration (MDA) for eliminating LF in Léogâne. We show that the salt enterprise because of its mixed product business strategy may have already reached the production capacity for delivering sufficient quantities of edible DEC-medicated salt to bring about LF transmission in the Léogâne study setting. Due to increasing revenues obtained from the sale of DEC salt over time, expansion of its delivery in the population, and greater cumulative impact on the survival of worms leading to shorter timelines to extinction, this strategy could also represent a significantly more cost-effective option than annual DEC tablet-based MDA for accomplishing LF elimination. Significance A social enterprise approach can offer an innovative market-based strategy by which edible salt fortified with DEC could be distributed to communities both on a financially sustainable basis and at sufficient quantity to eliminate LF. Deployment of similarly fashioned intervention strategies would improve current efforts to successfully accomplish the goal of LF elimination, particularly in difficult-to-control settings. With less than three years remaining for meeting the initial 2020 target set by WHO for accomplishing the global elimination of Lymphatic Filariasis (LF), concerns are emerging regarding the feasibility of meeting this goal using the current tablet-based Mass Drug Administration strategy. Salt fortified with the antifilarial drug, diethylcarbamazine (DEC), could offer an intervention that avoids many of the barriers connected with tablet-based elimination programs. We analyzed the economic performance and cost-effectiveness of a novel DEC-salt social enterprise developed and tested in Léogâne arrondissement, Haiti, as a particularly significant strategy for accomplishing sustainable LF elimination in such complex settings. We show that because of increasing revenue from the sale of the DEC salt over time, expansion of its delivery in the population, and the adverse effect of continuous consumption of the drug on worms, the delivery of DEC through a salt enterprise can represent a significantly more cost-effective option than annual DEC tablet-based MDA for accomplishing LF elimination in settings, like Léogâne. We indicate that development of policy and research into how to deploy similarly-fashioned interventions, or work with the salt industry to increase population use of medicated salt, would improve present efforts to successfully accomplish the elimination of LF.
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Affiliation(s)
- Swarnali Sharma
- Department of Biological Sciences, University of Notre Dame, Galvin Life Science Center, Notre Dame, IN, United States of America
| | - Morgan E Smith
- Department of Biological Sciences, University of Notre Dame, Galvin Life Science Center, Notre Dame, IN, United States of America
| | - James Reimer
- Grosse Pointe Park, MI, United States of America
| | | | - Jean M Brissau
- College of Science, University of Notre Dame, Notre Dame, IN, United States of America
| | - Marie C Donahue
- Eck Institute of Global Health, University of Notre Dame, Notre Dame, IN, United States of America
| | - Clarence E Carter
- College of Science, University of Notre Dame, Notre Dame, IN, United States of America
| | - Edwin Michael
- Department of Biological Sciences, University of Notre Dame, Galvin Life Science Center, Notre Dame, IN, United States of America
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11
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Turner HC, Walker M, Pion SDS, McFarland DA, Bundy DAP, Basáñez M. Economic evaluations of onchocerciasis interventions: a systematic review and research needs. Trop Med Int Health 2019; 24:788-816. [PMID: 31013395 PMCID: PMC6617745 DOI: 10.1111/tmi.13241] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To provide a systematic review of economic evaluations that has been conducted for onchocerciasis interventions, to summarise current key knowledge and to identify research gaps. METHOD A systematic review of the literature was conducted on the 8th of August 2018 using the PubMed (MEDLINE) and ISI Web of Science electronic databases. No date or language stipulations were applied to the searches. RESULTS We identified 14 primary studies reporting the results of economic evaluations of onchocerciasis interventions, seven of which were cost-effectiveness analyses. The studies identified used a variety of different approaches to estimate the costs of the investigated interventions/programmes. Originally, the studies only quantified the benefits associated with preventing blindness. Gradually, methods improved and also captured onchocerciasis-associated skin disease. Studies found that eliminating onchocerciasis would generate billions in economic benefits. The majority of the cost-effectiveness analyses evaluated annual mass drug administration (MDA). The estimated cost per disability-adjusted life year (DALY) averted of annual MDA varies between US$3 and US$30 (cost year variable). CONCLUSIONS The cost benefit and cost effectiveness of onchocerciasis interventions have consistently been found to be very favourable. This finding provides strong evidential support for the ongoing efforts to eliminate onchocerciasis from endemic areas. Although these results are very promising, there are several important research gaps that need to be addressed as we move towards the 2020 milestones and beyond.
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Affiliation(s)
- Hugo C. Turner
- Oxford University Clinical Research UnitWellcome Africa Asia ProgrammeHo Chi Minh CityVietnam
- Centre for Tropical Medicine and Global HealthNuffield Department of MedicineUniversity of OxfordOxfordUK
| | - Martin Walker
- London Centre for Neglected Tropical Disease ResearchDepartment of Pathobiology and Population SciencesRoyal Veterinary CollegeHatfieldUK
- London Centre for Neglected Tropical Disease ResearchDepartment of Infectious Disease EpidemiologySchool of Public HealthImperial College LondonLondonUK
| | - Sébastien D. S. Pion
- Institut de Recherche pour le DéveloppementUMI 233‐INSERMU1175‐Montpellier UniversityMontpellierFrance
| | | | | | - María‐Gloria Basáñez
- London Centre for Neglected Tropical Disease ResearchDepartment of Infectious Disease EpidemiologySchool of Public HealthImperial College LondonLondonUK
- MRC Centre for Global Infectious Disease AnalysisDepartment of Infectious Disease EpidemiologySchool of Public HealthImperial College LondonLondonUK
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12
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Sutherland CS, Tediosi F. Is the elimination of 'sleeping sickness' affordable? Who will pay the price? Assessing the financial burden for the elimination of human African trypanosomiasis Trypanosoma brucei gambiense in sub-Saharan Africa. BMJ Glob Health 2019; 4:e001173. [PMID: 31139437 PMCID: PMC6509604 DOI: 10.1136/bmjgh-2018-001173] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 03/07/2019] [Accepted: 03/09/2019] [Indexed: 12/11/2022] Open
Abstract
Introduction Programme to eliminate neglected tropical diseases (NTDs) have gained global recognition, and may allow for improvements to universal health coverage and poverty alleviation. It is hoped that elimination of human African trypanosomiasis (HAT) Trypanosoma brucei gambiense (Tbg) would assist in this goal, but the financial costs are still unknown. The objective of this analysis was to forecast the financial burden of direct costs of HAT Tbg to funders and society. Methods In order to estimate the total costs to health services and individuals: (1) potential elimination programmes were defined; (2) the direct costs of programmes were calculated; (3) the per case out-of-pocket payments (OOPs) by programme and financial risk protection indicators were estimated. The total estimated costs for control and elimination programme were reported up till 2020 in international dollars. The mean results for both direct programme costs and OOPs were calculated and reported along with 95% CIs. Results Across sub-Saharan Africa, HAT Tbg maintaining ‘Control’ would lead to a decline in cases and cost US$630.6 million. In comparison, the cost of ‘Elimination’ programme ranged from US$410.9 million to US$1.2 billion. Maintaining ‘Control’ would continue to cause impoverishment and financial hardship to households; while all ‘Elimination’ programme would lead to significant reductions in poverty. Conclusion Overall, the total costs of either control or elimination programme would be near US$1 billion in the next decade. However, only elimination programme will reduce the number of cases and improve financial risk protection for households who are impacted by HAT Tbg.
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Affiliation(s)
- C Simone Sutherland
- Institute of Pharmaceutical Medicine, Universitat Basel Medizinische Fakultat, Basel, Switzerland.,Department of Epidemiology and Public Health (EPH), Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Fabrizio Tediosi
- Department of Epidemiology and Public Health (EPH), Swiss Tropical and Public Health Institute, Basel, Switzerland.,Department of Public Health, University of Basel, Basel, Switzerland
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13
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Colebunders R, Basáñez MG, Siling K, Post RJ, Rotsaert A, Mmbando B, Suykerbuyk P, Hopkins A. From river blindness control to elimination: bridge over troubled water. Infect Dis Poverty 2018; 7:21. [PMID: 29587844 PMCID: PMC5872540 DOI: 10.1186/s40249-018-0406-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 03/12/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An estimated 25 million people are currently infected with onchocerciasis (a parasitic infection caused by the filarial nematode Onchocerca volvulus and transmitted by Simulium vectors), and 99% of these are in sub-Saharan Africa. The African Programme for Onchocerciasis Control closed in December 2015 and the World Health Organization has established a new structure, the Expanded Special Project for the Elimination of Neglected Tropical Diseases for the coordination of technical support for activities focused on five neglected tropical diseases in Africa, including onchocerciasis elimination. AIMS In this paper we argue that despite the delineation of a reasonably well-defined elimination strategy, its implementation will present particular difficulties in practice. We aim to highlight these in an attempt to ensure that they are well understood and that effective plans can be laid to solve them by the countries concerned and their international partners. CONCLUSIONS A specific concern is the burden of disease caused by onchocerciasis-associated epilepsy in hyperendemic zones situated in countries experiencing difficulties in strengthening their onchocerciasis control programmes. These difficulties should be identified and programmes supported during the transition from morbidity control to interruption of transmission and elimination.
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Affiliation(s)
| | - Maria-Gloria Basáñez
- London Centre for Neglected Tropical Disease Research, Imperial College London, London, UK
| | - Katja Siling
- Institute of Tropical Medicine, Antwerp, Belgium
- London School of Hygiene & Tropical Medicine, London, UK
| | - Rory J. Post
- London School of Hygiene & Tropical Medicine, London, UK
- Liverpool John Moores University, Liverpool, UK
| | - Anke Rotsaert
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Bruno Mmbando
- National Institute for Medical Research, Tanga, Tanzania
| | | | - Adrian Hopkins
- Neglected and Disabling diseases of Poverty Consultant, Gravesend, Kent, UK
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14
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Pemberton-Ross P, Chitnis N, Pothin E, Smith TA. A stochastic model for the probability of malaria extinction by mass drug administration. Malar J 2017; 16:376. [PMID: 28923063 PMCID: PMC5604301 DOI: 10.1186/s12936-017-2010-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 09/02/2017] [Indexed: 11/13/2022] Open
Abstract
Background Mass drug administration (MDA) has been proposed as an intervention to achieve local extinction of malaria. Although its effect on the reproduction number is short lived, extinction may subsequently occur in a small population due to stochastic fluctuations. This paper examines how the probability of stochastic extinction depends on population size, MDA coverage and the reproduction number under control, Rc. A simple compartmental model is developed which is used to compute the probability of extinction using probability generating functions. The expected time to extinction in small populations after MDA for various scenarios in this model is calculated analytically. Results The results indicate that mass drug administration (Firstly, Rc must be sustained at Rc < 1.2 to avoid the rapid re-establishment of infections in the population. Secondly, the MDA must produce effective cure rates of >95% to have a non-negligible probability of successful elimination. Stochastic fluctuations only significantly affect the probability of extinction in populations of about 1000 individuals or less. The expected time to extinction via stochastic fluctuation is less than 10 years only in populations less than about 150 individuals. Clustering of secondary infections and of MDA distribution both contribute positively to the potential probability of success, indicating that MDA would most effectively be administered at the household level. Conclusions There are very limited circumstances in which MDA will lead to local malaria elimination with a substantial probability. Electronic supplementary material The online version of this article (doi:10.1186/s12936-017-2010-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Peter Pemberton-Ross
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4051, Basel, Switzerland.,University of Basel, Petersplatz 1, Basel, Switzerland
| | - Nakul Chitnis
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4051, Basel, Switzerland.,University of Basel, Petersplatz 1, Basel, Switzerland
| | - Emilie Pothin
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4051, Basel, Switzerland.,University of Basel, Petersplatz 1, Basel, Switzerland
| | - Thomas A Smith
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, 4051, Basel, Switzerland. .,University of Basel, Petersplatz 1, Basel, Switzerland.
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15
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Steinmann P, Reed SG, Mirza F, Hollingsworth TD, Richardus JH. Innovative tools and approaches to end the transmission of Mycobacterium leprae. THE LANCET. INFECTIOUS DISEASES 2017; 17:e298-e305. [DOI: 10.1016/s1473-3099(17)30314-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 03/26/2017] [Accepted: 04/06/2017] [Indexed: 12/23/2022]
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16
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Kim YE, Stolk WA, Tanner M, Tediosi F. Modelling the health and economic impacts of the elimination of river blindness (onchocerciasis) in Africa. BMJ Glob Health 2017; 2:e000158. [PMID: 28589011 PMCID: PMC5435253 DOI: 10.1136/bmjgh-2016-000158] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 01/09/2017] [Accepted: 01/13/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Onchocerciasis (river blindness) is endemic mostly in remote and rural areas in sub-Saharan Africa. The treatment goal for onchocerciasis has shifted from control to elimination in Africa. For investment decisions, national and global policymakers need evidence on benefits, costs and risks of elimination initiatives. METHODS We estimated the health benefits using a dynamical transmission model, and the needs for health workforce and outpatient services for elimination strategies in comparison to a control mode. We then estimated the associated costs to both health systems and households and the potential economic impacts in terms of income gains. RESULTS The elimination of onchocerciasis in Africa would avert 4.3 million-5.6 million disability-adjusted life years over 2013-2045 when compared with staying in the control mode, and also reduce the required number of community volunteers by 45-53% and community health workers by 56-60%. The elimination of onchocerciasis in Africa when compared with the control mode is predicted to save outpatient service costs by $37.2 million-$39.9 million and out-of-pocket payments by $25.5 million-$26.9 million over 2013-2045, and generate economic benefits up to $5.9 billion-$6.4 billion in terms of income gains. DISCUSSION The elimination of onchocerciasis in Africa would lead to substantial health and economic benefits, reducing the needs for health workforce and outpatient services. To realise these benefits, the support and collaboration of community, national and global policymakers would be needed to sustain the elimination strategies.
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Affiliation(s)
- Young Eun Kim
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Wilma A Stolk
- Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Marcel Tanner
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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17
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Fitzpatrick C, Fleming FM, Madin-Warburton M, Schneider T, Meheus F, Asiedu K, Solomon AW, Montresor A, Biswas G. Benchmarking the Cost per Person of Mass Treatment for Selected Neglected Tropical Diseases: An Approach Based on Literature Review and Meta-regression with Web-Based Software Application. PLoS Negl Trop Dis 2016; 10:e0005037. [PMID: 27918573 PMCID: PMC5137870 DOI: 10.1371/journal.pntd.0005037] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 09/13/2016] [Indexed: 11/29/2022] Open
Abstract
Background Advocacy around mass treatment for the elimination of selected Neglected Tropical Diseases (NTDs) has typically put the cost per person treated at less than US$ 0.50. Whilst useful for advocacy, the focus on a single number misrepresents the complexity of delivering “free” donated medicines to about a billion people across the world. We perform a literature review and meta-regression of the cost per person per round of mass treatment against NTDs. We develop a web-based software application (https://healthy.shinyapps.io/benchmark/) to calculate setting-specific unit costs against which programme budgets and expenditures or results-based pay-outs can be benchmarked. Methods We reviewed costing studies of mass treatment for the control, elimination or eradication of lymphatic filariasis, schistosomiasis, soil-transmitted helminthiasis, onchocerciasis, trachoma and yaws. These are the main 6 NTDs for which mass treatment is recommended. We extracted financial and economic unit costs, adjusted to a standard definition and base year. We regressed unit costs on the number of people treated and other explanatory variables. Regression results were used to “predict” country-specific unit cost benchmarks. Results We reviewed 56 costing studies and included in the meta-regression 34 studies from 23 countries and 91 sites. Unit costs were found to be very sensitive to economies of scale, and the decision of whether or not to use local volunteers. Financial unit costs are expected to be less than 2015 US$ 0.50 in most countries for programmes that treat 100 thousand people or more. However, for smaller programmes, including those in the “last mile”, or those that cannot rely on local volunteers, both economic and financial unit costs are expected to be higher. Discussion The available evidence confirms that mass treatment offers a low cost public health intervention on the path towards universal health coverage. However, more costing studies focussed on elimination are needed. Unit cost benchmarks can help in monitoring value for money in programme plans, budgets and accounts, or in setting a reasonable pay-out for results-based financing mechanisms. Advocacy around mass treatment for the elimination of selected Neglected Tropical Diseases (NTDs) has typically put the cost per person treated at less than US$ 0.50. Whilst useful for advocacy, the focus on a single number misrepresents the complexity of delivering “free” donated medicines to about a billion people across the world. Given the increasing focus of the NTD community on value for money and, in the context of universal health coverage, of the global health community on outreach beyond health facilities, there was a need for greater nuance. We performed the most comprehensive literature review and first regression analysis of differences between settings in the cost per person treated against six NTDs (excluding the cost of individual medicines). We considered more than ten possible drivers of cost. We found, for example, that the unit cost of treatment depends very much on the number of people treated (economies of scale). We then developed a web-based software application (https://healthy.shinyapps.io/benchmark/) that can be used to predict setting-specific unit costs against which programme budgets and expenditures or results-based pay-outs can be benchmarked.
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Affiliation(s)
- Christopher Fitzpatrick
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
- * E-mail:
| | | | - Matthew Madin-Warburton
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
- University of York, York, United Kingdom
| | | | - Filip Meheus
- Health Economics Unit, University of Cape Town, Cape Town, South Africa
| | - Kingsley Asiedu
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Anthony W. Solomon
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Antonio Montresor
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Gautam Biswas
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
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Lessons Learned From Developing an Eradication Investment Case for Lymphatic Filariasis. ADVANCES IN PARASITOLOGY 2016; 94:393-417. [PMID: 27756458 DOI: 10.1016/bs.apar.2016.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In the last few years, the concepts of disease elimination and eradication have again gained consideration from the global health community, with Guinea worm disease (dracunculiasis) on track to become the first parasitic disease to be eradicated. Given the many complex and interlinking issues involved in committing to a disease eradication initiative, such commitments must be based on a solid assessment of a broad range of factors. In this chapter, we discuss the value and implications of undertaking a systematic and fact-based analysis of the overall situation prior to embarking on an elimination or eradication programme. As an example, we draw upon insights gained from a series of lymphatic filariasis (LF) studies from our research group that adopted an eradication investment case (EIC) framework. The justification for EICs, and related epidemiological, geospatial and other mathematical/operational research modelling, stems from the necessity for proper planning prior to committing to disease eradication. Across all considerations for LF eradication, including: time, treatments, level of investments necessary, health impact, cost-effectiveness, and broader economic benefits, scaling-up mass drug administration coverage to all endemic communities immediately provided the most favourable results. The coherent and consistent pursuit of eradication goals, operationally tailored to a given socioecological system and based on integrated measures of available tools will lead relatively rapidly to elimination in many parts of endemic areas and provide the cornerstone towards eradication.
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Basáñez M, Walker M, Turner H, Coffeng L, de Vlas S, Stolk W. River Blindness: Mathematical Models for Control and Elimination. ADVANCES IN PARASITOLOGY 2016; 94:247-341. [PMID: 27756456 DOI: 10.1016/bs.apar.2016.08.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Human onchocerciasis (river blindness) is one of the few neglected tropical diseases (NTDs) whose control strategies have been informed by mathematical modelling. With the change in focus from elimination of the disease burden to elimination of Onchocerca volvulus, much remains to be done to refine, calibrate and validate existing models. Under the impetus of the NTD Modelling Consortium, the teams that developed EPIONCHO and ONCHOSIM have joined forces to compare and improve these frameworks to better assist ongoing elimination efforts. We review their current versions and describe how they are being used to address two key questions: (1) where can onchocerciasis be eliminated with current intervention strategies by 2020/2025? and (2) what alternative/complementary strategies could help to accelerate elimination where (1) cannot be achieved? The control and elimination of onchocerciasis from the African continent is at a crucial crossroad. The African Programme for Onchocerciasis Control closed at the end of 2015, and although a new platform for support and integration of NTD control has been launched, the disease will have to compete with a myriad of other national health priorities at a pivotal time in the road to elimination. However, never before had onchocerciasis control a better arsenal of intervention strategies as well as diagnostics. It is, therefore, timely to present two models of different geneses and modelling traditions as they come together to produce robust decision-support tools. We start by describing the structural and parametric assumptions of EPIONCHO and ONCHOSIM; we continue by summarizing the modelling of current treatment strategies with annual (or biannual) mass ivermectin distribution and introduce a number of alternative strategies, including other microfilaricidal therapies (such as moxidectin), macrofilaricidal (anti-wolbachial) treatments, focal vector control and the possibility of an onchocerciasis vaccine. We conclude by discussing challenges, opportunities and future directions.
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