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Owusu-Kyei K, Chen H, Chileshe M, Quintó L, Sibley M, Figueroa-Romero A, Llach M, Ramírez M, Bofill A, Samai M, Menéndez C. Impact of oral azithromycin and intermittent preventive treatment with sulfadoxine-pyrimethamine regimen on child mortality in Sierra Leone: trial protocol for a randomised, two-arm, double-blinded, placebo-controlled clinical trial (ICARIA). Trials 2024; 25:626. [PMID: 39334260 PMCID: PMC11430122 DOI: 10.1186/s13063-024-08443-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 09/02/2024] [Indexed: 09/30/2024] Open
Abstract
BACKGROUND Azithromycin has been shown to be beneficial in preventing infectious diseases, including malaria, infectious diarrhoea and pneumonia. A cluster randomised control trial on azithromycin MDA in children in Niger, Malawi and Tanzania found a reduction in all-cause under-five (U5) mortality in communities who received azithromycin compared to placebo. However, the reduction was largest and statistically significant only in Niger. The purpose of this trial is to evaluate the impact of azithromycin plus intermittent preventive treatment in infants (IPTi), recently renamed by the World Health Organisation as perennial malaria chemoprevention (PMC), with sulfadoxine-pyrimethamine (SP) on all-cause mortality up to 18 months of age in children living in areas of high mortality burden through the Expanded Program on Immunisation (EPI) in Sierra Leone. METHODS The Improving Care through Azithromycin Research for Infants in Africa (ICARIA) trial is a phase III two-arm, individually randomised, double-blinded, placebo-controlled trial administering oral AZI (20 mg/kg bodyweight) at three time points to children attending EPI visits in Sierra Leone. A total of 20,560 infants attending the first EPI contact at around 6 weeks of age are recruited and randomised to AZI or placebo in a 1:1 ratio. The second and third AZI/placebo doses are given at 9 and 15 months of age. The primary outcome of the trial is all-cause mortality rate at 18 months of age assessed through mortality surveillance. Other trial outcomes include the impact on antimicrobial resistance, and on the immune response to certain key routine EPI immunisations, the safety of the intervention, the prevalence of SP resistance markers and the feasibility, and acceptability of adding AZI to the EPI programme. DISCUSSION The trial will provide the evidence needed to inform policy regarding the adoption and large-scale implementation of AZI in areas of high-mortality burden in sub-Saharan Africa. TRIAL REGISTRATION ClinicalTrials.gov NCT04235816. Registered on 22 January 2020. Pan-African Clinical Trials Registry PACTR202004540256535. Registered on 14 April 2020.
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Affiliation(s)
- Kwabena Owusu-Kyei
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain.
| | - Haily Chen
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
- Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Maureen Chileshe
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
- Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Llorenç Quintó
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
- Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Centro de Investigação Em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Maya Sibley
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
| | - Antía Figueroa-Romero
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
- Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Mireia Llach
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
| | - Máximo Ramírez
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
| | - Andreu Bofill
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
| | - Mohamed Samai
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Clara Menéndez
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
- Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Centro de Investigação Em Saúde de Manhiça (CISM), Maputo, Mozambique
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Gatiba P, Laury J, Steinhardt L, Hwang J, Thwing JI, Zulliger R, Emerson C, Gutman JR. Contextual Factors to Improve Implementation of Malaria Chemoprevention in Children: A Systematic Review. Am J Trop Med Hyg 2024; 110:69-78. [PMID: 38081055 PMCID: PMC10793032 DOI: 10.4269/ajtmh.23-0478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/15/2023] [Indexed: 01/05/2024] Open
Abstract
Malaria remains a leading cause of childhood morbidity and mortality in sub-Saharan Africa, particularly among children under 5 years of age. To help address this challenge, the WHO recommends chemoprevention for certain populations. For children and infants, the WHO recommends seasonal malaria chemoprevention (SMC), perennial malaria chemoprevention (PMC; formerly intermittent preventive treatment in infants [IPTi]), and, more recently, intermittent preventive treatment in school children (IPTsc). This review describes the contextual factors, including feasibility, acceptability, health equity, financial considerations, and values and preferences, that impact implementation of these strategies. A systematic search was conducted on July 5, 2022, and repeated April 13, 2023, to identify relevant literature. Two reviewers independently screened titles for eligibility, extracted data from eligible articles, and identified and summarized themes. Of 6,295 unique titles identified, 65 were included. The most frequently evaluated strategy was SMC (n = 40), followed by IPTi (n = 18) and then IPTsc (n = 6). Overall, these strategies were highly acceptable, although with IPTsc, there were community concerns with providing drugs to girls of reproductive age and the use of nonmedical staff for drug distribution. For SMC, door-to-door delivery resulted in higher coverage, improved caregiver acceptance, and reduced cost. Lower adherence was noted when caregivers were charged with giving doses 2 and 3 unsupervised. For SMC and IPTi, travel distances and inclement weather limited accessibility. Sensitization and caregiver education efforts, retention of high-quality drug distributors, and improved transportation were key to improving coverage. Additional research is needed to understand the role of community values and preferences in chemoprevention implementation.
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Affiliation(s)
- Peris Gatiba
- Public Health Institute, Oakland, California
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jessica Laury
- Public Health Institute, Oakland, California
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Laura Steinhardt
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jimee Hwang
- U.S. President’s Malaria Initiative, Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Julie I. Thwing
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rose Zulliger
- U.S. President’s Malaria Initiative, United States Agency for International Development, Washington, District of Columbia
| | - Courtney Emerson
- U.S. President’s Malaria Initiative, Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Julie R. Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Centers for Disease Control and Prevention, Atlanta, Georgia
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Cirera L, Sacoor C, Meremikwu M, Ranaivo L, Manun'Ebo MF, Pons-Duran C, Arikpo D, Ramirez M, Ramponi F, Figueroa-Romero A, Gonzalez R, Maly C, Roman E, Sicuri E, Pagnoni F, Menéndez C. Cost-effectiveness of community-based distribution of intermittent preventive treatment of malaria in pregnancy in Madagascar, Mozambique, Nigeria, and the Democratic Republic of Congo. BMJ Glob Health 2023; 8:e010238. [PMID: 37479498 PMCID: PMC10364184 DOI: 10.1136/bmjgh-2022-010238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 07/05/2023] [Indexed: 07/23/2023] Open
Abstract
INTRODUCTION Malaria in pregnancy is a major driver of maternal and infant mortality in sub-Saharan Africa. The WHO recommends the administration of intermittent preventive treatment with sulfadoxine pyrimethamine (IPTp-SP) at antenatal care (ANC) visits. Despite being a highly cost-effective strategy, IPTp-SP coverage and uptake remains low. A pilot project was conducted to assess the cost-effectiveness (CE) of community-based delivery of IPTp (C-IPTp) in addition to ANC delivery to increase IPTp uptake in the Democratic Republic of Congo (DRC), Madagascar (MDG), Mozambique (MOZ) and Nigeria (NGA). METHODS Costs and CE estimates of C-IPTp were calculated according to two scenarios: (1) costs in 'programmatic mode' (ie, costs if C-IPTp was to be implemented by national health systems) and (2) costs from the pilot project. The effectiveness of C-IPTp was obtained through estimates of the averted disability-adjusted life-years (DALYs) associated with maternal clinical malaria and anaemia, low birth weight and neonatal mortality. RESULTS Net incremental costs of C-IPTp ranged between US$6138-US$47 177 (DRC), US$5552-US$31 552 (MDG), US$10 202-US$53 221 (MOZ) and US$667-US$28 645 (NGA) per 1000 pregnant women, under scenarios (1) and (2), respectively. Incremental cost-effectiveness ratios (ICERs) ranged between US$15-US$119 in DRC, US$9-US$53 in MDG, US$104-US$543 in MOZ and US$2-US$66 in NGA per DALY averted, under scenarios (1) and (2), respectively. ICERs fall below the WHO recommended CE threshold based on the gross domestic product per capita. CONCLUSION Findings suggest that C-IPTp is a highly cost-effective intervention. Results can inform policy decisions on adopting and optimising effective interventions for preventing malaria in pregnancy.
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Affiliation(s)
- Laia Cirera
- Maternal, Child and Reproductive Health Initiative, Barcelona Institute for Global Health, Barcelona, Spain
| | | | - Martin Meremikwu
- Cross River Health and Demographic Surveillance System, University of Calabar, Calabar, Nigeria
| | - Louise Ranaivo
- Malagasy Associates for Numerical Information and Statistical Analysis (MANISA), Antananarivo, Madagascar
| | - Manu F Manun'Ebo
- Bureau d'Étude et de Gestion de l'Information Statistique (BEGIS), Kinshasa, Congo (the Democratic Republic of the)
| | - Clara Pons-Duran
- Maternal, Child and Reproductive Health Initiative, Barcelona Institute for Global Health, Barcelona, Spain
| | - Dachi Arikpo
- Cross River Health and Demographic Surveillance System, University of Calabar, Calabar, Nigeria
| | - Maximo Ramirez
- Maternal, Child and Reproductive Health Initiative, Barcelona Institute for Global Health, Barcelona, Spain
| | - Francesco Ramponi
- Maternal, Child and Reproductive Health Initiative, Barcelona Institute for Global Health, Barcelona, Spain
| | - Antia Figueroa-Romero
- Maternal, Child and Reproductive Health Initiative, Barcelona Institute for Global Health, Barcelona, Spain
| | - Raquel Gonzalez
- Maternal, Child and Reproductive Health Initiative, Barcelona Institute for Global Health, Barcelona, Spain
- Manhiça Health Research Center, Manhiça, Mozambique
| | - Christina Maly
- Jhpiego, Johns Hopkins University Affiliate, Baltimore, Maryland, USA
| | - Elaine Roman
- Jhpiego, Johns Hopkins University Affiliate, Baltimore, Maryland, USA
| | - Elisa Sicuri
- Maternal, Child and Reproductive Health Initiative, Barcelona Institute for Global Health, Barcelona, Spain
- Department of Health Policy, The London School of Economics and Political Science, London, UK
| | - Franco Pagnoni
- Maternal, Child and Reproductive Health Initiative, Barcelona Institute for Global Health, Barcelona, Spain
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Fombah AE, Chen H, Owusu-Kyei K, Quinto L, Gonzalez R, Williams J, Berne MLL, Wassenaar M, Jalloh A, Sunders JHC, Ramirez M, Bertran-Cobo C, Saute F, Ekouevi DK, Briand V, Kamara ARY, Sesay T, Samai M, Menendez C. Coverage of intermittent preventive treatment of malaria in infants after four years of implementation in Sierra Leone. Malar J 2023; 22:145. [PMID: 37127633 PMCID: PMC10151216 DOI: 10.1186/s12936-023-04575-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/24/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Intermittent Preventive Treatment of malaria in infants (IPTi) is a malaria control strategy consisting of the administration of an anti-malarial drug alongside routine immunizations. So far, this is being implemented nationwide in Sierra Leone only. IPTi has been renamed as Perennial Malaria Chemoprevention -PMC-, accounting for its recently recommended expansion into the second year of life. Before starting a pilot implementation on PMC, the currently implemented strategy and malaria prevalence were assessed in young children in selected areas of Sierra Leone. METHODS A cross-sectional, community-based, multi-stage cluster household survey was conducted from November to December 2021 in selected districts of the Northern and northwestern provinces of Sierra Leone among 10-23 months old children, whose caretakers gave written informed consent to participate in the survey. Coverage of IPTi and malaria prevalence-assessed with rapid diagnostic tests-were calculated using percentages and 95% confidence intervals weighted for the sampling design and adjusted for non-response within clusters. Factors associated with RDT + and iPTi coverage were also assessed. RESULTS A total of 720 children were recruited. Coverage of three IPTi doses was 50.57% (368/707; 95% CI 45.38-55.75), while prevalence of malaria infection was 28.19% (95% CI 24.81-31.84). Most children had received IPTi1 (80.26%, 574/707; 95% CI 75.30-84.44), and IPTi2 (80.09%, 577/707; 95% CI 76.30-83.40) and over half of the children also received IPTi3 (57.72%, 420/707; 95% CI 53.20-62.11). The uptake of each IPTi dose was lower than that of the vaccines administered at the same timepoint at all contacts. CONCLUSION In Sierra Leone, half of the children received the three recommended doses of IPTi indicating an increase in its uptake compared to previous data of just a third of children receiving the intervention. However, efforts need to be made in improving IPTi coverage, especially in the planned expansion of the strategy into the second year of life following recent WHO guidelines.
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Affiliation(s)
- Augustin E Fombah
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain.
- Ministry of Health and Sanitation, Freetown, Sierra Leone.
| | - Haily Chen
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
| | - Kwabena Owusu-Kyei
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
| | - Llorenç Quinto
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
- Manhiça Health Research Center, Manhiça, Mozambique
| | - Raquel Gonzalez
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
- Manhiça Health Research Center, Manhiça, Mozambique
| | - Julian Williams
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Mireia LLach Berne
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
| | - Myrte Wassenaar
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
- University Medical Center Utrecht - Utrecht University, Utrecht, The Netherlands
| | - Abubakarr Jalloh
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Joe-Henry C Sunders
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Maximo Ramirez
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
| | - Cesc Bertran-Cobo
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
| | | | | | - Valérie Briand
- National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, University of Bordeaux, Bordeaux, France
| | - Anitta R Y Kamara
- National Malaria Control Program, Directorate of Disease Prevention and Control, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Tom Sesay
- Directorate of Research and Training, Ministry of Health and Sanitation, Freetown, Sierra Leone
| | - Mohamed Samai
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
- Ministry of Health and Sanitation, Directorate Research and Training, Freetown, Sierra Leone
| | - Clara Menendez
- Barcelona Institute for Global Health, Hospital Clinic-University of Barcelona, Barcelona, Spain
- Manhiça Health Research Center, Manhiça, Mozambique
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No Roots, No Fruits: Marcel Tanner's Scholarly Contribution, Achievements in Capacity Building, and Impact in Global Health. Diseases 2022; 10:diseases10040116. [PMID: 36547202 PMCID: PMC9777716 DOI: 10.3390/diseases10040116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/11/2022] [Accepted: 11/16/2022] [Indexed: 12/05/2022] Open
Abstract
On 1 October 2022, Marcel Tanner celebrated his 70th birthday with his family and friends on the River Rhein in Basel. Trained in epidemiology (Ph.D.) and public health (MPH), Tanner devoted his entire working life to research, teaching, and capacity building. Indeed, he built up productive partnerships, fostered multinational consortia, served on numerous scientific and strategic advisory boards, and contributed measurably to improving people's health and well-being. We systematically searched the Web of Science Core Collection to identify Tanner's scholarly contribution and pursued an in-depth analysis of his scientific oeuvre including the main areas of research, pathogens, diseases, and health systems, and the geographical foci of his scholarly activities. Additionally, we examined Tanner's impact on personal and institutional capacity building in the arena of global health. We also invited a handful of colleagues to describe their experiences while working with Marcel Tanner. What transpires is a considerable breadth and depth of peer-reviewed publications in tropical medicine; epidemiology, environmental, and occupational health; parasitology; and infectious diseases. More than a third of the 622 peer-reviewed articles, the first piece published in 1978, focused on various aspects of the protozoan parasite Plasmodium and the disease it causes: malaria. Tanner trained, taught, and inspired generations of students, scientists, and practitioners all over the world. His unique ability to bring people and institutions together to work in partnership is at the heart of an impactful career in global health.
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Marathe A, Shi R, Mendez-Lopez A, Hu Z, Lewis B, Rabinovich R, Chaccour CJ, Rist C. Potential impact of 5 years of ivermectin mass drug administration on malaria outcomes in high burden countries. BMJ Glob Health 2021; 6:bmjgh-2021-006424. [PMID: 34764146 PMCID: PMC8587489 DOI: 10.1136/bmjgh-2021-006424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 10/18/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The global progress against malaria has slowed significantly since 2017. As the current malaria control tools seem insufficient to get the trend back on track, several clinical trials are investigating ivermectin mass drug administration (iMDA) as a potential additional vector control tool; however, the health impacts and cost-effectiveness of this new strategy remain unclear. METHODS We developed an analytical tool based on a full factorial experimental design to assess the potential impact of iMDA in nine high burden sub-Saharan African countries. The simulated iMDA regimen was assumed to be delivered monthly to the targeted population for 3 months each year from 2023 to 2027. A broad set of parameters of ivermectin efficacy, uptake levels and global intervention scenarios were used to predict averted malaria cases and deaths. We then explored the potential averted treatment costs, expected implementation costs and cost-effectiveness ratios under different scenarios. RESULTS In the scenario where coverage of malaria interventions was maintained at 2018 levels, we found that iMDA in these nine countries has the potential to reverse the predicted growth of malaria burden by averting 20-50 million cases and 36 000-90 000 deaths with an assumed efficacy of 20%. If iMDA has an efficacy of 40%, we predict between 40-99 million cases and 73 000-179 000 deaths will be averted with an estimated net cost per case averted between US$2 and US$7, and net cost per death averted between US$1460 and US$4374. CONCLUSION This study measures the potential of iMDA to reverse the increasing number of malaria cases for several sub-Saharan African countries. With additional efficacy information from ongoing clinical trials and country-level modifications, our analytical tool can help determine the appropriate uptake strategies of iMDA by calculating potential marginal gains and costs under different scenarios.
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Affiliation(s)
- Achla Marathe
- Network Systems Science and Advanced Computing Division, Biocomplexity Institute, University of Virginia, Charlottesville, Virginia, USA.,Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Ruoding Shi
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Ana Mendez-Lopez
- Department of Preventive Medicine, Public Health and Microbiology, Autonomous University of Madrid, Madrid, Spain.,Barcelona Institute for Global Health, ISGlobal, Barcelona, Spain
| | - Zhihao Hu
- Department of Statistics, Virginia Tech, Blacksburg, Virginia, USA
| | - Bryan Lewis
- Network Systems Science and Advanced Computing Division, Biocomplexity Institute, University of Virginia, Charlottesville, Virginia, USA
| | | | - Carlos J Chaccour
- Barcelona Institute for Global Health, ISGlobal, Barcelona, Spain.,Universitat de Navarra, Pamplona, Spain
| | - Cassidy Rist
- Department of Population Health Sciences, Virginia Tech, Blacksburg, Virginia, USA
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Conteh L, Shuford K, Agboraw E, Kont M, Kolaczinski J, Patouillard E. Costs and Cost-Effectiveness of Malaria Control Interventions: A Systematic Literature Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1213-1222. [PMID: 34372987 PMCID: PMC8324482 DOI: 10.1016/j.jval.2021.01.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 12/18/2020] [Accepted: 01/04/2021] [Indexed: 05/05/2023]
Abstract
OBJECTIVES To systematically review the literature on the unit cost and cost-effectiveness of malaria control. METHODS Ten databases and gray literature sources were searched to identify evidence relevant to the period 2005 to 2018. Studies with primary financial or economic cost data from malaria endemic countries that took a provider, provider and household, or societal perspective were included. RESULTS We identified 103 costing studies. The majority of studies focused on individual rather than combined interventions, notably insecticide-treated bed nets and treatment, and commonly took a provider perspective. A third of all studies took place in 3 countries. The median provider economic cost of protecting 1 person per year ranged from $1.18 to $5.70 with vector control and from $0.53 to $5.97 with chemoprevention. The median provider economic cost per case diagnosed with rapid diagnostic tests was $6.06 and per case treated $9.31 or $89.93 depending on clinical severity. Other interventions did not share enough similarities to be summarized. Cost drivers were rarely reported. Cost-effectiveness of malaria control was reiterated, but care in methodological and reporting standards is required to enhance data transferability. CONCLUSIONS Important information that can support resource allocation was reviewed. Given the variability in methods and reporting, global efforts to follow existing standards are required for the evidence to be most useful outside their study context, supplemented by guidance on options for transferring existing data across settings.
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Affiliation(s)
- Lesong Conteh
- Department of Health Policy, London School of Economics and Political Science, London, England, UK; School of Public Health, Imperial College London, St Mary's Campus, Paddington, England, UK
| | - Kathryn Shuford
- Department of Health Policy, London School of Economics and Political Science, London, England, UK
| | - Efundem Agboraw
- Vector Biology, Liverpool School of Tropical Medicine, Liverpool, England, UK
| | - Mara Kont
- Department of Infectious Disease Epidemiology, MRC Centre for Global Infectious Disease Analysis, Imperial College London, England, UK
| | - Jan Kolaczinski
- Department of the Global Malaria Programme, World Health Organization, Geneva, Switzerland
| | - Edith Patouillard
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland.
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Pulkki-Brännström AM, Haghparast-Bidgoli H, Batura N, Colbourn T, Azad K, Banda F, Banda L, Borghi J, Fottrell E, Kim S, Makwenda C, Ojha AK, Prost A, Rosato M, Shaha SK, Sinha R, Costello A, Skordis J. Participatory learning and action cycles with women's groups to prevent neonatal death in low-resource settings: A multi-country comparison of cost-effectiveness and affordability. Health Policy Plan 2021; 35:1280-1289. [PMID: 33085753 PMCID: PMC7886438 DOI: 10.1093/heapol/czaa081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2020] [Indexed: 11/14/2022] Open
Abstract
WHO recommends participatory learning and action cycles with women's groups as a cost-effective strategy to reduce neonatal deaths. Coverage is a determinant of intervention effectiveness, but little is known about why cost-effectiveness estimates vary significantly. This article reanalyses primary cost data from six trials in India, Nepal, Bangladesh and Malawi to describe resource use, explore reasons for differences in costs and cost-effectiveness ratios, and model the cost of scale-up. Primary cost data were collated, and costing methods harmonized. Effectiveness was extracted from a meta-analysis and converted to neonatal life-years saved. Cost-effectiveness ratios were calculated from the provider perspective compared with current practice. Associations between unit costs and cost-effectiveness ratios with coverage, scale and intensity were explored. Scale-up costs and outcomes were modelled using local unit costs and the meta-analysis effect estimate for neonatal mortality. Results were expressed in 2016 international dollars. The average cost was $203 (range: $61-$537) per live birth. Start-up costs were large, and spending on staff was the main cost component. The cost per neonatal life-year saved ranged from $135 to $1627. The intervention was highly cost-effective when using income-based thresholds. Variation in cost-effectiveness across trials was strongly correlated with costs. Removing discounting of costs and life-years substantially reduced all cost-effectiveness ratios. The cost of rolling out the intervention to rural populations ranges from 1.2% to 6.3% of government health expenditure in the four countries. Our analyses demonstrate the challenges faced by economic evaluations of community-based interventions evaluated using a cluster randomized controlled trial design. Our results confirm that women's groups are a cost-effective and potentially affordable strategy for improving birth outcomes among rural populations.
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Affiliation(s)
- Anni-Maria Pulkki-Brännström
- Department of Epidemiology and Global Health, Umeå University, Umeå S-901 87, Sweden.,UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Hassan Haghparast-Bidgoli
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Neha Batura
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Tim Colbourn
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Kishwar Azad
- Perinatal Care Project, Diabetic Association of Bangladesh, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh
| | | | - Lumbani Banda
- Parent and Child Health Initiative (PACHI), Area 14 Plot 171, Lilongwe, Malawi
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Edward Fottrell
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Sungwook Kim
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Charles Makwenda
- Parent and Child Health Initiative (PACHI), Area 14 Plot 171, Lilongwe, Malawi
| | - Amit Kumar Ojha
- Ekjut, Plot no. - 556B, Potka Chakradharpur, West Singhbhum, Pin - 833102, Jharkhand, India
| | - Audrey Prost
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Mikey Rosato
- Women and Children First (UK), United House, North Road, London, N7 9DP, UK
| | - Sanjit Kumer Shaha
- Perinatal Care Project, Diabetic Association of Bangladesh, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh
| | - Rajesh Sinha
- Ekjut, Plot no. - 556B, Potka Chakradharpur, West Singhbhum, Pin - 833102, Jharkhand, India
| | - Anthony Costello
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
| | - Jolene Skordis
- UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK
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Obagha EC, Ajayi I, Abdullahi GA, Umeokonkwo CD. Clients' satisfaction with preventive services for malaria during pregnancy in Anambra state, Nigeria. BMC Public Health 2020; 20:1660. [PMID: 33148250 PMCID: PMC7641832 DOI: 10.1186/s12889-020-09767-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 10/26/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Burden of Malaria in pregnancy (MIP) is still high despite availability of proven cost-effective interventions. Considerable progress has been made on improving antenatal attendance, but MIP preventive services utilization remains low. Factors responsible for this include dissatisfaction with the services provided. We assessed clients' satisfaction with preventative services for malaria during pregnancy delivered at antenatal clinics (ANC) in Anambra State Nigeria. METHOD We conducted a cross-sectional study among 284 pregnant women attending ANC using multistage sampling technique. Pre-tested semi-structured interviewer-administered questionnaire was used to collect information on socio-demographics, knowledge of malaria in pregnancy services and satisfaction with services. Responses to questions on satisfaction was on a 5-point Likert scale. A cut off of ≥75% of composite score was used to classify respondents as satisfied. For knowledge, every correct answer was scored 1 and incorrect 0; ≥75% of the composite score was graded as good knowledge. Chi square and logistic regression were used to test for association between client satisfaction and independent variables. RESULTS The mean age of participants is 28 years±4.4 years. Overall, 62.2% were satisfied with quality of preventive services for malaria during pregnancy. However, 64.8 and 57.8% were dissatisfied with cost of healthcare and interpersonal relationship with the health workers (HWs). Majority of the respondents (88.73%) had poor knowledge of malaria preventive services during pregnancy. Type of facility (Adjusted odds ratio [aOR] = 2.11; 95%CI: 1.20-3.71) and knowledge (aOR: 0.41; 95%CI: 0.18-0.90) were independently associated with satisfaction with interpersonal relationship. Type of facility (aOR: 0.47; 95%CI: 0.27-0.80) and employment status (aOR: 3.07; 95%CI: 1.39-6.74) were also independently associated with satisfaction with cost of healthcare. CONCLUSION A fair proportion of respondents were satisfied with the preventive services for malaria during pregnancy provided even though most were dissatisfied with the cost of assessing care and interpersonal relationship with health workers. Uninterrupted availability of long lasting insecticide treated bed nets and intermittent preventive treatment for malaria at all health facilities, subsidized cost of malaria-related commodities, and incentives for good customer satisfaction ratings may remediate the described barriers to seeking preventative care for malaria during pregnancy.
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Affiliation(s)
- Emmanuel Chijioke Obagha
- Nigerian Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria.
- Epidemiology Unit, Public Health Department, Anambra State Ministry of Health, Awka, Anambra State, Nigeria.
- University of Ibadan, Oyo State, Nigeria.
| | - IkeOluwakpo Ajayi
- Nigerian Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria
- University of Ibadan, Oyo State, Nigeria
| | - Gobir A Abdullahi
- Nigerian Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria
- Ahmadu Bello University Zaria, Kaduna State, Nigeria
| | - Chukwuma David Umeokonkwo
- Nigerian Field Epidemiology and Laboratory Training Programme, Abuja, Nigeria
- Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital Abakiliki, Ebonyi State, Nigeria
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10
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Alonso S, Chaccour CJ, Elobolobo E, Nacima A, Candrinho B, Saifodine A, Saute F, Robertson M, Zulliger R. The economic burden of malaria on households and the health system in a high transmission district of Mozambique. Malar J 2019; 18:360. [PMID: 31711489 PMCID: PMC6849240 DOI: 10.1186/s12936-019-2995-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 11/04/2019] [Indexed: 03/17/2023] Open
Abstract
Background Malaria remains a leading cause of morbidity and mortality in Mozambique. Increased investments in malaria control have reduced the burden, but few studies have estimated the costs of malaria in the country. This paper estimates the economic costs associated with malaria care to households and to the health system in the high burden district of Mopeia in central Mozambique. Methods Malaria care-seeking and morbidity costs were routinely collected among 1373 households with at least one child enrolled in an active case detection (ACD) cohort in Mopeia, and through cross-sectional surveys with 824 families in 2017 and 805 families in 2018. Household costs included direct medical expenses, transportation and opportunity costs of the time lost due to illness. Structured questionnaires were used to estimate the health system costs associated with malaria care in all 13 district health facilities. Cost estimations followed an ingredient-based approach with a top-down allocation approach for health system expenses. Results Among participants in cross-sectional studies, households sought care for nine severe malaria cases requiring hospital admission and for 679 uncomplicated malaria cases. Median household costs associated with uncomplicated malaria among individuals of all ages were US$ 3.46 (IQR US$ 0.07–22.41) and US$ 81.08 (IQR US$ 39.34–88.38) per severe case. Median household costs were lower among children under five (ACD cohort): US$ 1.63 (IQR US$ 0.00–7.79) per uncomplicated case and US$ 64.90 (IQR US$ 49.76–80.96) per severe case. Opportunity costs were the main source of household costs. Median health system costs associated with malaria among patients of all ages were US$ 4.34 (IQR US$ 4.32–4.35) per uncomplicated case and US$ 26.56 (IQR US$ 18.03–44.09) per severe case. Considering household and health system costs, the overall cost of malaria care to society was US$ 7.80 per uncomplicated case and US$ 107.64 per severe case, representing an economic malaria burden of US$ 332,286.24 (IQR US$ 186,355.84–1,091,212.90) per year only in Mopeia. Conclusions Despite the provision of free malaria services, households in Mopeia incur significant direct and indirect costs associated with the disease. Furthermore, the high malaria cost on the Mozambican health system underscores the need to strengthen malaria prevention to reduce the high burden and improve productivity in the region.
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Affiliation(s)
- Sergi Alonso
- Centro de Investigação em Saúde de Manhiça, Bairro Cambeve, Rua 12, Distrito da Manhiça, CP 1929, Maputo, Mozambique. .,ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain. .,Centre for Primary Care and Public Health, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK.
| | - Carlos J Chaccour
- Centro de Investigação em Saúde de Manhiça, Bairro Cambeve, Rua 12, Distrito da Manhiça, CP 1929, Maputo, Mozambique.,ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Eldo Elobolobo
- Centro de Investigação em Saúde de Manhiça, Bairro Cambeve, Rua 12, Distrito da Manhiça, CP 1929, Maputo, Mozambique
| | - Amilcar Nacima
- Centro de Investigação em Saúde de Manhiça, Bairro Cambeve, Rua 12, Distrito da Manhiça, CP 1929, Maputo, Mozambique
| | | | - Abuchahama Saifodine
- U.S. President's Malaria Initiative, US Agency for International Development, Maputo, Mozambique
| | - Francisco Saute
- Centro de Investigação em Saúde de Manhiça, Bairro Cambeve, Rua 12, Distrito da Manhiça, CP 1929, Maputo, Mozambique
| | | | - Rose Zulliger
- U.S. President's Malaria Initiative and Malaria Branch, Division of Parasitic Diseases and Malaria, U.S. Centers for Disease Control and Prevention, Maputo, Mozambique
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11
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Winskill P, Walker PG, Cibulskis RE, Ghani AC. Prioritizing the scale-up of interventions for malaria control and elimination. Malar J 2019; 18:122. [PMID: 30961603 PMCID: PMC6454681 DOI: 10.1186/s12936-019-2755-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 03/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A core set of intervention and treatment options are recommended by the World Health Organization for use against falciparum malaria. These are treatment, long-lasting insecticide-treated bed nets, indoor residual spraying, and chemoprevention options. Both domestic and foreign aid funding for these tools is limited. When faced with budget restrictions, the introduction and scale-up of intervention and treatment options must be prioritized. METHODS Estimates of the cost and impact of different interventions were combined with a mathematical model of malaria transmission to estimate the most cost-effective prioritization of interventions. The incremental cost effectiveness ratio was used to select between scaling coverage of current interventions or the introduction of an additional intervention tool. RESULTS Prevention, in the form of vector control, is highly cost effective and scale-up is prioritized in all scenarios. Prevention reduces malaria burden and therefore allows treatment to be implemented in a more cost-effective manner by reducing the strain on the health system. The chemoprevention measures (seasonal malaria chemoprevention and intermittent preventive treatment in infants) are additional tools that, provided sufficient funding, are implemented alongside treatment scale-up. Future tools, such as RTS,S vaccine, have impact in areas of higher transmission but were introduced later than core interventions. CONCLUSIONS In a programme that is budget restricted, it is essential that investment in available tools be effectively prioritized to maximize impact for a given investment. The cornerstones of malaria control: vector control and treatment, remain vital, but questions of when to scale and when to introduce other interventions must be rigorously assessed. This quantitative analysis considers the scale-up or core interventions to inform decision making in this area.
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Affiliation(s)
- Peter Winskill
- MRC Centre of Global Infectious Disease Analysis, School of Public Health, Faculty of Medicine, Imperial College London, St Mary's Campus, London, W2 1PG, UK.
| | - Patrick G Walker
- MRC Centre of Global Infectious Disease Analysis, School of Public Health, Faculty of Medicine, Imperial College London, St Mary's Campus, London, W2 1PG, UK
| | | | - Azra C Ghani
- MRC Centre of Global Infectious Disease Analysis, School of Public Health, Faculty of Medicine, Imperial College London, St Mary's Campus, London, W2 1PG, UK
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12
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Yogavel M, Nettleship JE, Sharma A, Harlos K, Jamwal A, Chaturvedi R, Sharma M, Jain V, Chhibber-Goel J, Sharma A. Structure of 6-hydroxymethyl-7,8-dihydropterin pyrophosphokinase-dihydropteroate synthase from Plasmodium vivax sheds light on drug resistance. J Biol Chem 2018; 293:14962-14972. [PMID: 30104413 DOI: 10.1074/jbc.ra118.004558] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/08/2018] [Indexed: 11/06/2022] Open
Abstract
The genomes of the malaria-causing Plasmodium parasites encode a protein fused of 6-hydroxymethyl-7,8-dihydropterin pyrophosphokinase (HPPK) and dihydropteroate synthase (DHPS) domains that catalyze sequential reactions in the folate biosynthetic pathway. Whereas higher organisms derive folate from their diet and lack the enzymes for its synthesis, most eubacteria and a number of lower eukaryotes including malaria parasites synthesize tetrahydrofolate via DHPS. Plasmodium falciparum (Pf) and Plasmodium vivax (Pv) HPPK-DHPSs are currently targets of drugs like sulfadoxine (SDX). The SDX effectiveness as an antimalarial drug is increasingly diminished by the rise and spread of drug-resistant mutations. Here, we present the crystal structure of PvHPPK-DHPS in complex with four substrates/analogs, revealing the bifunctional PvHPPK-DHPS architecture in an unprecedented state of enzymatic activation. SDX's effect on HPPK-DHPS is due to 4-amino benzoic acid (pABA) mimicry, and the PvHPPK-DHPS structure sheds light on the SDX-binding cavity, as well as on mutations that effect SDX potency. We mapped five dominant drug resistance mutations in PvHPPK-DHPS: S382A, A383G, K512E/D, A553G, and V585A, most of which occur individually or in clusters proximal to the pABA-binding site. We found that these resistance mutations subtly alter the intricate enzyme/pABA/SDX interactions such that DHPS affinity for pABA is diminished only moderately, but its affinity for SDX is changed substantially. In conclusion, the PvHPPK-DHPS structure rationalizes and unravels the structural bases for SDX resistance mutations and highlights architectural features in HPPK-DHPSs from malaria parasites that can form the basis for developing next-generation anti-folate agents to combat malaria parasites.
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Affiliation(s)
- Manickam Yogavel
- From the Molecular Medicine-Structural Parasitology Group, International Centre for Genetic Engineering and Biotechnology, New Delhi 110067, India,
| | - Joanne E Nettleship
- the Division of Structural Biology, Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, United Kingdom, and.,the Oxford Protein Production Facility, United Kingdom Research Complex at Harwell, Rutherford Appleton Laboratory, Oxford OX11 0FA, United Kingdom
| | - Akansha Sharma
- From the Molecular Medicine-Structural Parasitology Group, International Centre for Genetic Engineering and Biotechnology, New Delhi 110067, India
| | - Karl Harlos
- the Division of Structural Biology, Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, United Kingdom, and
| | - Abhishek Jamwal
- From the Molecular Medicine-Structural Parasitology Group, International Centre for Genetic Engineering and Biotechnology, New Delhi 110067, India
| | - Rini Chaturvedi
- From the Molecular Medicine-Structural Parasitology Group, International Centre for Genetic Engineering and Biotechnology, New Delhi 110067, India
| | - Manmohan Sharma
- From the Molecular Medicine-Structural Parasitology Group, International Centre for Genetic Engineering and Biotechnology, New Delhi 110067, India
| | - Vitul Jain
- the Division of Structural Biology, Wellcome Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, United Kingdom, and
| | - Jyoti Chhibber-Goel
- From the Molecular Medicine-Structural Parasitology Group, International Centre for Genetic Engineering and Biotechnology, New Delhi 110067, India
| | - Amit Sharma
- From the Molecular Medicine-Structural Parasitology Group, International Centre for Genetic Engineering and Biotechnology, New Delhi 110067, India
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13
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Tizifa TA, Kabaghe AN, McCann RS, van den Berg H, Van Vugt M, Phiri KS. Prevention Efforts for Malaria. CURRENT TROPICAL MEDICINE REPORTS 2018; 5:41-50. [PMID: 29629252 PMCID: PMC5879044 DOI: 10.1007/s40475-018-0133-y] [Citation(s) in RCA: 69] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Malaria remains a global burden contributing to morbidity and mortality especially in children under 5 years of age. Despite the progress achieved towards malaria burden reduction, achieving elimination in more countries remains a challenge. This article aims to review the prevention and control strategies for malaria, to assess their impact towards reducing the disease burden and to highlight the best practices observed. RECENT FINDINGS Use of long-lasting insecticide-treated nets and indoor residual spraying has resulted a decline in the incidence and prevalence of malaria in Sub-Saharan Africa. Other strategies such as larval source management have been shown to reduce mosquito density but require further evaluation. New methods under development such as house improvement have demonstrated to minimize disease burden but require further evidence on efficacy. Development of the RTS,S/AS01 malaria vaccine that provides protection in under-five children has provided further progress in efforts of malaria control. SUMMARY There has been a tremendous reduction in malaria burden in the past decade; however, more work is required to fill the necessary gaps to eliminate malaria.
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Affiliation(s)
- Tinashe A. Tizifa
- Training and Research Unit of Excellence (TRUE), Public Health Department, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Alinune N. Kabaghe
- Training and Research Unit of Excellence (TRUE), Public Health Department, College of Medicine, University of Malawi, Blantyre, Malawi
- Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Robert S. McCann
- Training and Research Unit of Excellence (TRUE), Public Health Department, College of Medicine, University of Malawi, Blantyre, Malawi
- Wageningen University and Research Center, Wageningen, Netherlands
| | | | - Michele Van Vugt
- Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Kamija S. Phiri
- Training and Research Unit of Excellence (TRUE), Public Health Department, College of Medicine, University of Malawi, Blantyre, Malawi
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14
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Lee BY, Bartsch SM, Stone NTB, Zhang S, Brown ST, Chatterjee C, DePasse JV, Zenkov E, Briët OJT, Mendis C, Viisainen K, Candrinho B, Colborn J. The Economic Value of Long-Lasting Insecticidal Nets and Indoor Residual Spraying Implementation in Mozambique. Am J Trop Med Hyg 2017; 96:1430-1440. [PMID: 28719286 PMCID: PMC5462583 DOI: 10.4269/ajtmh.16-0744] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Malaria-endemic countries have to decide how much of their limited resources for vector control to allocate toward implementing long-lasting insecticidal nets (LLINs) versus indoor residual spraying (IRS). To help the Mozambique Ministry of Health use an evidence-based approach to determine funding allocation toward various malaria control strategies, the Global Fund convened the Mozambique Modeling Working Group which then used JANUS, a software platform that includes integrated computational economic, operational, and clinical outcome models that can link with different transmission models (in this case, OpenMalaria) to determine the economic value of vector control strategies. Any increase in LLINs (from 80% baseline coverage) or IRS (from 80% baseline coverage) would be cost-effective (incremental cost-effectiveness ratios ≤ $114/disability-adjusted life year averted). However, LLIN coverage increases tend to be more cost-effective than similar IRS coverage increases, except where both pyrethroid resistance is high and LLIN usage is low. In high-transmission northern regions, increasing LLIN coverage would be more cost-effective than increasing IRS coverage. In medium-transmission central regions, changing from LLINs to IRS would be more costly and less effective. In low-transmission southern regions, LLINs were more costly and less effective than IRS, due to low LLIN usage. In regions where LLINs are more cost-effective than IRS, it is worth considering prioritizing LLIN coverage and use. However, IRS may have an important role in insecticide resistance management and epidemic control. Malaria intervention campaigns are not a one-size-fits-all solution, and tailored approaches are necessary to account for the heterogeneity of malaria epidemiology.
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Affiliation(s)
- Bruce Y Lee
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah M Bartsch
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nathan T B Stone
- Pittsburgh Supercomputing Center, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Shufang Zhang
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
| | - Shawn T Brown
- Pittsburgh Supercomputing Center, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | | | - Jay V DePasse
- Pittsburgh Supercomputing Center, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Eli Zenkov
- Pittsburgh Supercomputing Center, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Olivier J T Briët
- University of Basel, Basel, Switzerland.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | - Kirsi Viisainen
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
| | - Baltazar Candrinho
- National Malaria Control Program, Mozambique Ministry of Health, Maputo, Mozambique
| | - James Colborn
- President's Malaria Initiative, Centers for Disease Control and Prevention, Washington, District of Columbia
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15
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Gunda R, Chimbari MJ. Cost-effectiveness analysis of malaria interventions using disability adjusted life years: a systematic review. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2017; 15:10. [PMID: 28680367 PMCID: PMC5494144 DOI: 10.1186/s12962-017-0072-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 06/24/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Malaria continues to be a public health problem despite past and on-going control efforts. For sustenance of control efforts to achieve the malaria elimination goal, it is important that the most cost-effective interventions are employed. This paper reviews studies on cost-effectiveness of malaria interventions using disability-adjusted life years. METHODS A review of literature was conducted through a literature search of international peer-reviewed journals as well as grey literature. Searches were conducted through Medline (PubMed), EMBASE and Google Scholar search engines. The searches included articles published in English for the period from 1996 to 2016. The inclusion criteria for the study were type of malaria intervention, year of publication and cost-effectiveness ratio in terms of cost per DALY averted. We included 40 studies which specifically used the DALY metric in cost-effectiveness analysis (CEA) of malaria interventions. RESULTS The majority of the reviewed studies (75%) were done using data from African settings with the majority of the interventions (60.0%) targeting all age categories. Interventions included case treatment, prophylaxis, vector control, insecticide treated nets, early detection, environmental management, diagnosis and educational programmes. Sulfadoxine-pyrimethamine was the most common drug of choice in malaria prophylaxis, while artemisinin-based combination therapies were the most common drugs for case treatment. Based on guidelines for CEA, most interventions proved cost-effective in terms of cost per DALYs averted for each intervention. CONCLUSION The DALY metric is a useful tool for determining the cost-effectiveness of malaria interventions. This paper demonstrates the importance of CEA in informing decisions made by policy makers.
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Affiliation(s)
- Resign Gunda
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Howard Campus, Durban, 4001 South Africa
| | - Moses John Chimbari
- School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Howard Campus, Durban, 4001 South Africa
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16
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Winskill P, Walker PG, Griffin JT, Ghani AC. Modelling the cost-effectiveness of introducing the RTS,S malaria vaccine relative to scaling up other malaria interventions in sub-Saharan Africa. BMJ Glob Health 2017; 2:e000090. [PMID: 28588994 PMCID: PMC5321383 DOI: 10.1136/bmjgh-2016-000090] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/21/2016] [Accepted: 08/24/2016] [Indexed: 01/06/2023] Open
Abstract
Objectives To evaluate the relative cost-effectiveness of introducing the RTS,S malaria vaccine in sub-Saharan Africa compared with further scale-up of existing interventions. Design A mathematical modelling and cost-effectiveness study. Setting Sub-Saharan Africa. Participants People of all ages. Interventions The analysis considers the introduction and scale-up of the RTS,S malaria vaccine and the scale-up of long-lasting insecticide-treated bed nets (LLINs), indoor residual spraying (IRS) and seasonal malaria chemoprevention (SMC). Main outcome measure The number of Plasmodium falciparum cases averted in all age groups over a 10-year period. Results Assuming access to treatment remains constant, increasing coverage of LLINs was consistently the most cost-effective intervention across a range of transmission settings and was found to occur early in the cost-effectiveness scale-up pathway. IRS, RTS,S and SMC entered the cost-effective pathway once LLIN coverage had been maximised. If non-linear production functions are included to capture the cost of reaching very high coverage, the resulting pathways become more complex and result in selection of multiple interventions. Conclusions RTS,S was consistently implemented later in the cost-effectiveness pathway than the LLINs, IRS and SMC but was still of value as a fourth intervention in many settings to reduce burden to the levels set out in the international goals.
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Affiliation(s)
- Peter Winskill
- Department of Infectious Disease Epidemiology, MRC Centre for Outbreak Analysis and Modelling, Imperial College London, London, UK
| | - Patrick Gt Walker
- Department of Infectious Disease Epidemiology, MRC Centre for Outbreak Analysis and Modelling, Imperial College London, London, UK
| | - Jamie T Griffin
- Department of Infectious Disease Epidemiology, MRC Centre for Outbreak Analysis and Modelling, Imperial College London, London, UK.,School of Mathematical Sciences, Queen Mary University of London, London, UK
| | - Azra C Ghani
- Department of Infectious Disease Epidemiology, MRC Centre for Outbreak Analysis and Modelling, Imperial College London, London, UK
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17
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Nonvignon J, Aryeetey GC, Issah S, Ansah P, Malm KL, Ofosu W, Tagoe T, Agyemang SA, Aikins M. Cost-effectiveness of seasonal malaria chemoprevention in upper west region of Ghana. Malar J 2016; 15:367. [PMID: 27423900 PMCID: PMC4947302 DOI: 10.1186/s12936-016-1418-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/04/2016] [Indexed: 11/29/2022] Open
Abstract
Background In Ghana, malaria is endemic and perennial (with significant seasonal variations in the three Northern Regions), accounting for 33 % of all deaths among children under 5 years old, with prevalence rates in children under-five ranging from 11 % in Greater Accra to 40 % in Northern Region. Ghana adopted the WHO-recommended Seasonal Malaria Chemoprevention (SMC) strategy with a trial in the Upper West Region in 2015. The objective of this study was to estimate the cost-effectiveness of seasonal malaria chemoprevention. Methods Costs were analysed from provider and societal perspectives and are reported in 2015 US$. Data on resource use (direct and indirect costs) of the SMC intervention were collected from intervention records and a survey in all districts and at regional level. Additional numbers of malaria cases and deaths averted by the intervention were estimated based on prevalence data obtained from an SMC effectiveness study in the region. Incremental cost-effectiveness ratios (ICERs) were estimated for the districts and region. Sensitivity analyses were conducted to test the robustness of the ICERs. Results The total financial cost of the intervention was US$1,142,040.80. The total economic cost was estimated to be US$7.96 million and US$2.66 million from the societal and provider perspectives, respectively. The additional numbers of cases estimated to be averted by the intervention were 24,881 and 808, respectively. The economic cost per child dosed was US$67.35 from societal perspective and US$22.53 from the provider perspective. The economic cost per additional case averted was US$107.06 from the provider perspective and US$319.96 from the societal perspective. The economic cost per additional child death averted by the intervention was US$3298.36 from the provider perspective and US$9858.02 from the societal perspective. The financial cost per the SMC intervention delivered to a child under-five was US$9.66. The ICERs were sensitive to mortality rate used. Conclusions The SMC intervention is economically beneficial in reducing morbidity in children under-5 years and presents a viable approach to improving under-five health in Ghana.
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Affiliation(s)
- Justice Nonvignon
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana, P. O. Box LG13, Legon, Ghana
| | - Genevieve Cecilia Aryeetey
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana, P. O. Box LG13, Legon, Ghana
| | - Shamwill Issah
- UK Department for International Development, Accra, Ghana
| | - Patrick Ansah
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
| | - Keziah L Malm
- National Malaria Control Programme, Ghana Health Service, Accra, Ghana
| | - Winfred Ofosu
- Upper West Regional Health Directorate, Ghana Health Service, Wa, Ghana
| | - Titus Tagoe
- Upper West Regional Health Directorate, Ghana Health Service, Wa, Ghana
| | - Samuel Agyei Agyemang
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana, P. O. Box LG13, Legon, Ghana
| | - Moses Aikins
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, University of Ghana, P. O. Box LG13, Legon, Ghana.
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18
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Santatiwongchai B, Chantarastapornchit V, Wilkinson T, Thiboonboon K, Rattanavipapong W, Walker DG, Chalkidou K, Teerawattananon Y. Methodological variation in economic evaluations conducted in low- and middle-income countries: information for reference case development. PLoS One 2015; 10:e0123853. [PMID: 25950443 PMCID: PMC4423853 DOI: 10.1371/journal.pone.0123853] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/1969] [Accepted: 07/20/1969] [Indexed: 11/18/2022] Open
Abstract
Information generated from economic evaluation is increasingly being used to inform health resource allocation decisions globally, including in low- and middle- income countries. However, a crucial consideration for users of the information at a policy level, e.g. funding agencies, is whether the studies are comparable, provide sufficient detail to inform policy decision making, and incorporate inputs from data sources that are reliable and relevant to the context. This review was conducted to inform a methodological standardisation workstream at the Bill and Melinda Gates Foundation (BMGF) and assesses BMGF-funded cost-per-DALY economic evaluations in four programme areas (malaria, tuberculosis, HIV/AIDS and vaccines) in terms of variation in methodology, use of evidence, and quality of reporting. The findings suggest that there is room for improvement in the three areas of assessment, and support the case for the introduction of a standardised methodology or reference case by the BMGF. The findings are also instructive for all institutions that fund economic evaluations in LMICs and who have a desire to improve the ability of economic evaluations to inform resource allocation decisions.
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Affiliation(s)
| | | | - Thomas Wilkinson
- NICE International, National Institute for Health and Care Excellence, London, United Kingdom
| | | | | | - Damian G Walker
- Global Health Program, Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Kalipso Chalkidou
- NICE International, National Institute for Health and Care Excellence, London, United Kingdom
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Sicuri E, Fernandes S, Macete E, González R, Mombo-Ngoma G, Massougbodgi A, Abdulla S, Kuwawenaruwa A, Katana A, Desai M, Cot M, Ramharter M, Kremsner P, Slustker L, Aponte J, Hanson K, Menéndez C. Economic evaluation of an alternative drug to sulfadoxine-pyrimethamine as intermittent preventive treatment of malaria in pregnancy. PLoS One 2015; 10:e0125072. [PMID: 25915616 PMCID: PMC4410941 DOI: 10.1371/journal.pone.0125072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 03/15/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended in HIV-negative women to avert malaria, while this relies on cotrimoxazole prophylaxis (CTXp) in HIV-positive women. Alternative antimalarials are required in areas where parasite resistance to antifolate drugs is high. The cost-effectiveness of IPTp with alternative drugs is needed to inform policy. METHODS The cost-effectiveness of 2-dose IPTp-mefloquine (MQ) was compared with IPTp-SP in HIV-negative women (Benin, Gabon, Mozambique and Tanzania). In HIV-positive women the cost-effectiveness of 3-dose IPTp-MQ added to CTXp was compared with CTXp alone (Kenya, Mozambique and Tanzania). The outcomes used were maternal clinical malaria, anaemia at delivery and non-obstetric hospital admissions. The poor tolerability to MQ was included as the value of women's loss of working days. Incremental cost-effectiveness ratios (ICERs) were calculated and threshold analysis undertaken. RESULTS For HIV-negative women, the ICER for IPTp-MQ versus IPTp-SP was 136.30 US$ (2012 US$) (95%CI 131.41; 141.18) per disability-adjusted life-year (DALY) averted, or 237.78 US$ (95%CI 230.99; 244.57), depending on whether estimates from Gabon were included or not. For HIV-positive women, the ICER per DALY averted for IPTp-MQ added to CTXp, versus CTXp alone was 6.96 US$ (95%CI 4.22; 9.70). In HIV-negative women, moderate shifts of variables such as malaria incidence, drug cost, and IPTp efficacy increased the ICERs above the cost-effectiveness threshold. In HIV-positive women the intervention remained cost-effective for a substantial (up to 21 times) increase in cost per tablet. CONCLUSIONS Addition of IPTp with an effective antimalarial to CTXp was very cost-effective in HIV-positive women. IPTp with an efficacious antimalarial was more cost-effective than IPTp-SP in HIV-negative women. However, the poor tolerability of MQ does not favour its use as IPTp. Regardless of HIV status, prevention of malaria in pregnancy with a highly efficacious, well tolerated antimalarial would be cost-effective despite its high price. TRIALS REGISTRATION ClinicalTrials.gov NCT 00811421; Pan African Trials Registry PACTR2010020001429343 and PACTR2010020001813440.
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Affiliation(s)
- Elisa Sicuri
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Silke Fernandes
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Eusebio Macete
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Raquel González
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Ghyslain Mombo-Ngoma
- Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Achille Massougbodgi
- Faculté des Sciences de la Santé (FSS), Université d’Abomey Calavi, Cotonou, Benin
| | | | | | - Abraham Katana
- Kenya Medical Research Institute (KEMRI)/Center for Global Health Research, Kisumu, Kenya
| | - Meghna Desai
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA and Kisumu, Kenya
| | - Michel Cot
- Institut de Recherche pour le Développement (IRD), Paris, France
- Université René Descartes, Paris, France
| | - Michael Ramharter
- Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University of Vienna, Vienna, Austria
| | - Peter Kremsner
- Centre de Recherches Médicales de Lambaréné (CERMEL), Albert Schweitzer Hospital, Lambaréné, Gabon
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Laurence Slustker
- Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, USA and Kisumu, Kenya
| | - John Aponte
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Kara Hanson
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Clara Menéndez
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- Manhiça Health Research Center (CISM), Manhiça, Mozambique
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Contrasting benefits of different artemisinin combination therapies as first-line malaria treatments using model-based cost-effectiveness analysis. Nat Commun 2014; 5:5606. [PMID: 25425081 PMCID: PMC4263185 DOI: 10.1038/ncomms6606] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 10/20/2014] [Indexed: 01/15/2023] Open
Abstract
There are currently several recommended drug regimens for uncomplicated falciparum malaria in Africa. Each has different properties that determine its impact on disease burden. Two major antimalarial policy options are artemether–lumefantrine (AL) and dihydroartemisinin–piperaquine (DHA–PQP). Clinical trial data show that DHA–PQP provides longer protection against reinfection, while AL is better at reducing patient infectiousness. Here we incorporate pharmacokinetic-pharmacodynamic factors, transmission-reducing effects and cost into a mathematical model and simulate malaria transmission and treatment in Africa, using geographically explicit data on transmission intensity and seasonality, population density, treatment access and outpatient costs. DHA–PQP has a modestly higher estimated impact than AL in 64% of the population at risk. Given current higher cost estimates for DHA–PQP, there is a slightly greater cost per case averted, except in areas with high, seasonally varying transmission where the impact is particularly large. We find that a locally optimized treatment policy can be highly cost effective for reducing clinical malaria burden. Several drug combinations with different properties are used for malaria treatment. Here, Okell et al. use a mathematical model to simulate malaria transmission and treatment with two drug combinations in Africa, and find that locally optimized policies can be highly cost effective for reducing malaria burden.
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Stuckey EM, Stevenson J, Galactionova K, Baidjoe AY, Bousema T, Odongo W, Kariuki S, Drakeley C, Smith TA, Cox J, Chitnis N. Modeling the cost effectiveness of malaria control interventions in the highlands of western Kenya. PLoS One 2014; 9:e107700. [PMID: 25290939 PMCID: PMC4188563 DOI: 10.1371/journal.pone.0107700] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Accepted: 08/22/2014] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Tools that allow for in silico optimization of available malaria control strategies can assist the decision-making process for prioritizing interventions. The OpenMalaria stochastic simulation modeling platform can be applied to simulate the impact of interventions singly and in combination as implemented in Rachuonyo South District, western Kenya, to support this goal. METHODS Combinations of malaria interventions were simulated using a previously-published, validated model of malaria epidemiology and control in the study area. An economic model of the costs of case management and malaria control interventions in Kenya was applied to simulation results and cost-effectiveness of each intervention combination compared to the corresponding simulated outputs of a scenario without interventions. Uncertainty was evaluated by varying health system and intervention delivery parameters. RESULTS The intervention strategy with the greatest simulated health impact employed long lasting insecticide treated net (LLIN) use by 80% of the population, 90% of households covered by indoor residual spraying (IRS) with deployment starting in April, and intermittent screen and treat (IST) of school children using Artemether lumefantrine (AL) with 80% coverage twice per term. However, the current malaria control strategy in the study area including LLIN use of 56% and IRS coverage of 70% was the most cost effective at reducing disability-adjusted life years (DALYs) over a five year period. CONCLUSIONS All the simulated intervention combinations can be considered cost effective in the context of available resources for health in Kenya. Increasing coverage of vector control interventions has a larger simulated impact compared to adding IST to the current implementation strategy, suggesting that transmission in the study area is not at a level to warrant replacing vector control to a school-based screen and treat program. These results have the potential to assist malaria control program managers in the study area in adding new or changing implementation of current interventions.
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Affiliation(s)
- Erin M. Stuckey
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Jennifer Stevenson
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Centre for Global Health Research, Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya
- Johns Hopkins Malaria Research Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Katya Galactionova
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Amrish Y. Baidjoe
- Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Teun Bousema
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Wycliffe Odongo
- Centre for Global Health Research, Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Simon Kariuki
- Centre for Global Health Research, Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Chris Drakeley
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Thomas A. Smith
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Jonathan Cox
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nakul Chitnis
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Comfort AB, van Dijk JH, Mharakurwa S, Stillman K, Gabert R, Korde S, Nachbar N, Derriennic Y, Musau S, Hamazakaza P, Zyambo KD, Zyongwe NM, Hamainza B, Thuma PE. Hospitalizations and costs incurred at the facility level after scale-up of malaria control: pre-post comparisons from two hospitals in Zambia. Am J Trop Med Hyg 2013; 90:20-32. [PMID: 24218409 PMCID: PMC3886421 DOI: 10.4269/ajtmh.13-0019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
There is little evidence on the impact of malaria control on the health system, particularly at the facility level. Using retrospective, longitudinal facility-level and patient record data from two hospitals in Zambia, we report a pre-post comparison of hospital admissions and outpatient visits for malaria and estimated costs incurred for malaria admissions before and after malaria control scale-up. The results show a substantial reduction in inpatient admissions and outpatient visits for malaria at both hospitals after the scale-up, and malaria cases accounted for a smaller proportion of total hospital visits over time. Hospital spending on malaria admissions also decreased. In one hospital, malaria accounted for 11% of total hospital spending before large-scale malaria control compared with < 1% after malaria control. The findings demonstrate that facility-level resources are freed up as malaria is controlled, potentially making these resources available for other diseases and conditions.
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Affiliation(s)
- Alison B. Comfort
- *Address correspondence to Alison B. Comfort, Abt Associates, 55 Wheeler St., Cambridge, MA 02138. E-mail:
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Sicuri E, Vieta A, Lindner L, Constenla D, Sauboin C. The economic costs of malaria in children in three sub-Saharan countries: Ghana, Tanzania and Kenya. Malar J 2013; 12:307. [PMID: 24004482 PMCID: PMC3844618 DOI: 10.1186/1475-2875-12-307] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 08/21/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Malaria causes significant mortality and morbidity in sub-Saharan Africa (SSA), especially among children less than five years of age (U5 children). Although the economic burden of malaria in this region has been assessed previously, the extent and variation of this burden remains unclear. This study aimed to estimate the economic costs of malaria in U5 children in three countries (Ghana, Tanzania and Kenya). METHODS Health system and household costs previously estimated were integrated with costs associated with co-morbidities, complications and productivity losses due to death. Several models were developed to estimate the expected treatment cost per episode per child, across different age groups, by level of severity and with or without controlling for treatment-seeking behaviour. Total annual costs (2009) were calculated by multiplying the treatment cost per episode according to severity by the number of episodes. Annual health system prevention costs were added to this estimate. RESULTS Household and health system costs per malaria episode ranged from approximately US$ 5 for non-complicated malaria in Tanzania to US$ 288 for cerebral malaria with neurological sequelae in Kenya. On average, up to 55% of these costs in Ghana and Tanzania and 70% in Kenya were assumed by the household, and of these costs 46% in Ghana and 85% in Tanzania and Kenya were indirect costs. Expected values of potential future earnings (in thousands) lost due to premature death of children aged 0-1 and 1-4 years were US$ 11.8 and US$ 13.8 in Ghana, US$ 6.9 and US$ 8.1 in Tanzania, and US$ 7.6 and US$ 8.9 in Kenya, respectively. The expected treatment costs per episode per child ranged from a minimum of US$ 1.29 for children aged 2-11 months in Tanzania to a maximum of US$ 22.9 for children aged 0-24 months in Kenya. The total annual costs (in millions) were estimated at US$ 37.8, US$ 131.9 and US$ 109.0 nationwide in Ghana, Tanzania and Kenya and included average treatment costs per case of US$ 11.99, US$ 6.79 and US$ 20.54, respectively. CONCLUSION This study provides important insight into the economic burden of malaria in SSA that may assist policy makers when designing future malaria control interventions.
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Affiliation(s)
- Elisa Sicuri
- Barcelona Centre for International Health Research (CRESIB, Hospital Clínic-Universitat de Barcelona), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Ana Vieta
- Health Economics and Outcome Research - IMS Health, Barcelona, Spain
| | - Leandro Lindner
- Health Economics and Outcome Research - IMS Health, Barcelona, Spain
| | - Dagna Constenla
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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De la Hoz Restrepo F, Porras Ramírez A, Rico Mendoza A, Córdoba F, Rojas DP. Artesunate + amodiaquine versus artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum malaria in the Colombian Pacific region: a noninferiority trial. Rev Soc Bras Med Trop 2013; 45:732-8. [PMID: 23295878 DOI: 10.1590/s0037-86822012000600015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 05/04/2012] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION In Colombia, there are no published studies for the treatment of uncomplicated Plasmodium falciparum malaria comparing artemisinin combination therapies. Hence, it is intended to demonstrate the non-inferior efficacy/safety profiles of artesunate + amodiaquine versus artemether-lumefantrine treatments. METHODS A randomized, controlled, open-label, noninferiority (Δ≤5%) clinical trial was performed in adults with uncomplicated P. falciparum malaria using the 28-day World Health Organization validated design/definitions. Patients were randomized 1:1 to either oral artesunate + amodiaquine or artemether-lumefantrine. The primary efficacy endpoint: adequate clinical and parasitological response; secondary endpoints: - treatment failures defined per the World Health Organization. SAFETY assessed through adverse events. RESULTS A total of 105 patients was included in each group: zero censored observations. Mean (95%CI - Confidence interval) adequate clinical and parasitological response rates: 100% for artesunate + amodiaquine and 99% for artemether-lumefantrine; the noninferiority criteria was met (Δ=1.7%). There was one late parasitological therapeutic failure (1%; artemether-lumefantrine group), typified by polymerase chain reaction as the MAD20 MSP1 allele. The fever clearance time (artesunate + amodiaquine group) was significantly shorter (p=0.002). Respectively, abdominal pain for artesunate + amodiaquine and artemether-lumefantrine was 1.9% and 3.8% at baseline (p=0.68) and 1% and 13.3% after treatment (p<0.001). CONCLUSIONS Uncomplicated P. falciparum malaria treatment with artesunate + amodiaquine is noninferior to the artemether-lumefantrine standard treatment. The efficacy/safety profiles grant further studies in this and similar populations.
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Cruz VO, Walt G. Brokering the boundary between science and advocacy: the case of intermittent preventive treatment among infants. Health Policy Plan 2012; 28:616-25. [PMID: 23161588 PMCID: PMC3753881 DOI: 10.1093/heapol/czs101] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The process of translating research into policy has gained considerable attention in recent years and a number of studies have investigated the nexus between the two ‘worlds’ of research and policy. One issue that has been little addressed is about the boundaries between research and advocacy: how far scientists do, or should, promote particular findings to policy makers and others. This article analyses a particular intervention in malaria control and the Consortium set up to accelerate its potential implementation. Using a framework that emphasizes the interplay of interests, institutions and ideas, it provides an example of how a network of committed researchers and funders attempted to follow a rational policy process, but faced conflicts and fundamental questions about their roles in generating scientific evidence and influencing global health policy. In an era of ever more and larger researcher groups and consortia, the findings offer insights and lessons to those engaged in the process of knowledge translation.
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Affiliation(s)
- Valeria Oliveira Cruz
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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Mori AT, Robberstad B. Pharmacoeconomics and its implication on priority-setting for essential medicines in Tanzania: a systematic review. BMC Med Inform Decis Mak 2012; 12:110. [PMID: 23016739 PMCID: PMC3472274 DOI: 10.1186/1472-6947-12-110] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 09/25/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Due to escalating treatment costs, pharmacoeconomic analysis has been assigned a key role in the quest for increased efficiency in resource allocation for drug therapies in high-income countries. The extent to which pharmacoeconomic analysis is employed in the same role in low-income countries is less well established. This systematic review identifies and briefly describes pharmacoeconomic studies which have been conducted in Tanzania and further assesses their influence in the selection of essential medicines. METHODS Pubmed, Embase, Cinahl and Cochrane databases were searched using "economic evaluation", "cost-effectiveness analysis", "cost-benefit analysis" AND "Tanzania" as search terms. We also scanned reference lists and searched in Google to identify other relevant articles. Only articles reporting full economic evaluations about drug therapies and vaccines conducted in Tanzania were included. The national essential medicine list and other relevant policy documents related to the identified articles were screened for information regarding the use of economic evaluation as a criterion for medicine selection. RESULTS Twelve pharmacoeconomic studies which met our inclusion criteria were identified. Seven studies were on HIV/AIDS, malaria and diarrhoea, the three highest ranked diseases on the disease burden in Tanzania. Six studies were on preventive and treatment interventions targeting pregnant women and children under the age of five years. The national essential medicine list and the other identified policy documents do not state the use of economic evaluation as one of the criteria which has influenced the listing of the drugs. CONCLUSION Country specific pharmacoeconomic analyses are too scarce and inconsistently used to have had a significant influence on the selection of essential medicines in Tanzania. More studies are required to fill the existing gap and to explore whether decision-makers have the ability to interpret and utilise pharmacoeconomic evidence. Relevant health authorities in Tanzania should also consider how to apply pharmacoeconomic analyses more consistently in the future priority-setting decisions for selection of essential medicines.
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Affiliation(s)
- Amani Thomas Mori
- Centre for International Health, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway
- Muhimbili University of Health and Allied Sciences, School of Pharmacy, P.O. Box 65013, Dar es Salaam, Tanzania
| | - Bjarne Robberstad
- Centre for International Health, University of Bergen, P.O. Box 7804, 5020 Bergen, Norway
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Bardají A, Bassat Q, Alonso PL, Menéndez C. Intermittent preventive treatment of malaria in pregnant women and infants: making best use of the available evidence. Expert Opin Pharmacother 2012; 13:1719-36. [PMID: 22775553 DOI: 10.1517/14656566.2012.703651] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Malaria continues to represent a huge global health burden on the most vulnerable populations. The Intermittent Preventive Treatment (IPT) strategy has been shown to be an efficacious intervention in preventing most of the deleterious effects of malaria in pregnant women and infants. Yet, the effectiveness of the IPT strategy may be impaired by the increasing resistance to sulfadoxine-pyrimethamine (SP), and the scarcity of alternative antimalarial drugs. AREAS COVERED This review examines all the available information on IPT, in an aim to provide the scientific community with a framework to understand the benefits and limitations of this malaria control strategy. It includes the understanding of the historical background of the IPT strategy, the drug's mechanisms of actions, updated information on current available evidence, the implications of drug resistance and choice of alternative drugs, and a comprehensive discussion on the perspectives of IPT for malaria control in pregnant women and infants. EXPERT OPINION IPT in pregnancy and infants is a cost-effective strategy that can contribute significantly to the control of malaria in endemic areas. Monitoring its effectiveness will allow tracking of progress, evaluation of the adequacy of currently used drugs and will highlight the eventual need for new therapies or alternative interventions.
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Affiliation(s)
- Azucena Bardají
- University of Barcelona, Hospital Clínic, Barcelona Centre for International Health Research, Roselló, 132, 08036, Barcelona, Spain.
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Senn N, Rarau P, Stanisic DI, Robinson L, Barnadas C, Manong D, Salib M, Iga J, Tarongka N, Ley S, Rosanas-Urgell A, Aponte JJ, Zimmerman PA, Beeson JG, Schofield L, Siba P, Rogerson SJ, Reeder JC, Mueller I. Intermittent preventive treatment for malaria in Papua New Guinean infants exposed to Plasmodium falciparum and P. vivax: a randomized controlled trial. PLoS Med 2012; 9:e1001195. [PMID: 22479155 PMCID: PMC3313928 DOI: 10.1371/journal.pmed.1001195] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 02/09/2012] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Intermittent preventive treatment in infants (IPTi) has been shown in randomized trials to reduce malaria-related morbidity in African infants living in areas of high Plasmodium falciparum (Pf) transmission. It remains unclear whether IPTi is an appropriate prevention strategy in non-African settings or those co-endemic for P. vivax (Pv). METHODS AND FINDINGS In this study, 1,121 Papua New Guinean infants were enrolled into a three-arm placebo-controlled randomized trial and assigned to sulfadoxine-pyrimethamine (SP) (25 mg/kg and 1.25 mg/kg) plus amodiaquine (AQ) (10 mg/kg, 3 d, n = 374), SP plus artesunate (AS) (4 mg/kg, 3 d, n = 374), or placebo (n = 373), given at 3, 6, 9 and 12 mo. Both participants and study teams were blinded to treatment allocation. The primary end point was protective efficacy (PE) against all episodes of clinical malaria from 3 to 15 mo of age. Analysis was by modified intention to treat. The PE (compared to placebo) against clinical malaria episodes (caused by all species) was 29% (95% CI, 10-43, p ≤ 0.001) in children receiving SP-AQ and 12% (95% CI, -11 to 30, p = 0.12) in those receiving SP-AS. Efficacy was higher against Pf than Pv. In the SP-AQ group, Pf incidence was 35% (95% CI, 9-54, p = 0.012) and Pv incidence was 23% (95% CI, 0-41, p = 0.048) lower than in the placebo group. IPTi with SP-AS protected only against Pf episodes (PE = 31%, 95% CI, 4-51, p = 0.027), not against Pv episodes (PE = 6%, 95% CI, -24 to 26, p = 0.759). Number of observed adverse events/serious adverse events did not differ between treatment arms (p > 0.55). None of the serious adverse events were thought to be treatment-related, and the vomiting rate was low in both treatment groups (1.4%-2.0%). No rebound in malaria morbidity was observed for 6 mo following the intervention. CONCLUSIONS IPTi using a long half-life drug combination is efficacious for the prevention of malaria and anemia in infants living in a region highly endemic for both Pf and Pv.
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Affiliation(s)
- Nicolas Senn
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Department of Medicine, University of Melbourne, Melbourne Australia
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Patricia Rarau
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Danielle I. Stanisic
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Infection and Immunity Division, Walter and Eliza Hall Institute, Melbourne, Australia
| | - Leanne Robinson
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Infection and Immunity Division, Walter and Eliza Hall Institute, Melbourne, Australia
| | - Céline Barnadas
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Infection and Immunity Division, Walter and Eliza Hall Institute, Melbourne, Australia
| | - Doris Manong
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Mary Salib
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Jonah Iga
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Nandao Tarongka
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Serej Ley
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | | | - John J. Aponte
- Barcelona Centre for International Health Research (CRESIB), Barcelona, Spain
| | - Peter A. Zimmerman
- Center for Global Health and Diseases, Case Western Reserve University, Cleveland, Ohio, United States of America
| | - James G. Beeson
- Infection and Immunity Division, Walter and Eliza Hall Institute, Melbourne, Australia
- Burnet Institute, Melbourne, Australia
| | - Louis Schofield
- Infection and Immunity Division, Walter and Eliza Hall Institute, Melbourne, Australia
| | - Peter Siba
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | | | | | - Ivo Mueller
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
- Infection and Immunity Division, Walter and Eliza Hall Institute, Melbourne, Australia
- Barcelona Centre for International Health Research (CRESIB), Barcelona, Spain
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Sicuri E, Bardají A, Sigauque B, Maixenchs M, Nhacolo A, Nhalungo D, Macete E, Alonso PL, Menéndez C. Costs associated with low birth weight in a rural area of Southern Mozambique. PLoS One 2011; 6:e28744. [PMID: 22174885 PMCID: PMC3236214 DOI: 10.1371/journal.pone.0028744] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 11/14/2011] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Low Birth Weight (LBW) is prevalent in low-income countries. Even though the economic evaluation of interventions to reduce this burden is essential to guide health policies, data on costs associated with LBW are scarce. This study aims to estimate the costs to the health system and to the household and the Disability Adjusted Life Years (DALYs) arising from infant deaths associated with LBW in Southern Mozambique. METHODS AND FINDINGS Costs incurred by the households were collected through exit surveys. Health system costs were gathered from data obtained onsite and from published information. DALYs due to death of LBW babies were based on local estimates of prevalence of LBW (12%), very low birth weight (VLBW) (1%) and of case fatality rates compared to non-LBW weight babies [for LBW (12%) and VLBW (80%)]. Costs associated with LBW excess morbidity were calculated on the incremental number of hospital admissions in LBW babies compared to non-LBW weight babies. Direct and indirect household costs for routine health care were 24.12 US$ (CI 95% 21.51; 26.26). An increase in birth weight of 100 grams would lead to a 53% decrease in these costs. Direct and indirect household costs for hospital admissions were 8.50 US$ (CI 95% 6.33; 10.72). Of the 3,322 live births that occurred in one year in the study area, health system costs associated to LBW (routine health care and excess morbidity) and DALYs were 169,957.61 US$ (CI 95% 144,900.00; 195,500.00) and 2,746.06, respectively. CONCLUSIONS This first cost evaluation of LBW in a low-income country shows that reducing the prevalence of LBW would translate into important cost savings to the health system and the household. These results are of relevance for similar settings and should serve to promote interventions aimed at improving maternal care.
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Affiliation(s)
- Elisa Sicuri
- Barcelona Centre for International Health Research CRESIB, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.
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van Vugt M, van Beest A, Sicuri E, van Tulder M, Grobusch MP. Malaria treatment and prophylaxis in endemic and nonendemic countries: evidence on strategies and their cost–effectiveness. Future Microbiol 2011; 6:1485-500. [DOI: 10.2217/fmb.11.138] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Artemisinin combination treatment is currently the preferred treatment strategy to combat malaria. However, the drug costs are considerably higher than for previously used therapies. This review discusses the cost–effectiveness of current malaria treatment and prophylaxis in endemic and nonendemic countries. For endemic countries, a systematic search for economic evaluations (i.e., cost–effectiveness, cost–utility and cost–benefit analyses) was conducted, looking at the use of Artemisinin combination treatments in children, pregnant women and other adults. In total, 24 studies were identified investigating the cost–effectiveness of malaria treatments with the focus on uncomplicated malaria, severe or prereferral treatment, all in combination with adequate diagnosis, and malaria prevention by intermittent preventive treatment, respectively. In areas with both Plasmodium falciparum and Plasmodium vivax transmission, artemether–lumefantrine and dihydroartemisinin–piperaquine, respectively, are currently the most cost-effective treatment options. Treatment of severe malaria with artesunate is more cost effective compared with treatment with quinine. For patients that live more than 6 h away from an appropriate healthcare facility, prereferral treatment proved to be more cost-effective compared with no prereferral intervention. Cost–effectiveness of intermittent preventive treatment in pregnant women (IPTp) was dependent an clinical attendance. IPT in infants with sulphadoxine–pyrimethamine (SP) is cost effective in sites with high malaria transmission. IPT in children with artesunate (AS + SP), amodiaquine (AQ) + SPQ or SP alone is a cost effective and safe intervention for reducing the burden of malaria in children in areas with markedly seasonal malaria transmission. Although there is a need for it, little is known about the cost–effectiveness of current approaches to malaria therapy in nonendemic countries and the cost–effectiveness of antimalarial chemoprophylaxis.
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Affiliation(s)
- Michèle van Vugt
- Infectious Diseases, Center for Tropical Medicine & Travel Medicine, Division of Internal Medicine, AIGHD, Academic Medical Center, University of Amsterdam, Meibergdreef 9, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Anne van Beest
- Department of economics, VU University Medical Center, Amsterdam, The Netherlands
| | - Elisa Sicuri
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain
| | - Maurits van Tulder
- Department of economics, VU University Medical Center, Amsterdam, The Netherlands
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White MT, Conteh L, Cibulskis R, Ghani AC. Costs and cost-effectiveness of malaria control interventions--a systematic review. Malar J 2011; 10:337. [PMID: 22050911 PMCID: PMC3229472 DOI: 10.1186/1475-2875-10-337] [Citation(s) in RCA: 179] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 11/03/2011] [Indexed: 11/10/2022] Open
Abstract
Background The control and elimination of malaria requires expanded coverage of and access to effective malaria control interventions such as insecticide-treated nets (ITNs), indoor residual spraying (IRS), intermittent preventive treatment (IPT), diagnostic testing and appropriate treatment. Decisions on how to scale up the coverage of these interventions need to be based on evidence of programme effectiveness, equity and cost-effectiveness. Methods A systematic review of the published literature on the costs and cost-effectiveness of malaria interventions was undertaken. All costs and cost-effectiveness ratios were inflated to 2009 USD to allow comparison of the costs and benefits of several different interventions through various delivery channels, across different geographical regions and from varying costing perspectives. Results Fifty-five studies of the costs and forty three studies of the cost-effectiveness of malaria interventions were identified, 78% of which were undertaken in sub-Saharan Africa, 18% in Asia and 4% in South America. The median financial cost of protecting one person for one year was $2.20 (range $0.88-$9.54) for ITNs, $6.70 (range $2.22-$12.85) for IRS, $0.60 (range $0.48-$1.08) for IPT in infants, $4.03 (range $1.25-$11.80) for IPT in children, and $2.06 (range $0.47-$3.36) for IPT in pregnant women. The median financial cost of diagnosing a case of malaria was $4.32 (range $0.34-$9.34). The median financial cost of treating an episode of uncomplicated malaria was $5.84 (range $2.36-$23.65) and the median financial cost of treating an episode of severe malaria was $30.26 (range $15.64-$137.87). Economies of scale were observed in the implementation of ITNs, IRS and IPT, with lower unit costs reported in studies with larger numbers of beneficiaries. From a provider perspective, the median incremental cost effectiveness ratio per disability adjusted life year averted was $27 (range $8.15-$110) for ITNs, $143 (range $135-$150) for IRS, and $24 (range $1.08-$44.24) for IPT. Conclusions A transparent evidence base on the costs and cost-effectiveness of malaria control interventions is provided to inform rational resource allocation by donors and domestic health budgets and the selection of optimal packages of interventions by malaria control programmes.
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Affiliation(s)
- Michael T White
- MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, London, UK.
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Sicuri E, Biao P, Hutton G, Tediosi F, Menendez C, Lell B, Kremsner P, Conteh L, Grobusch MP. Cost-effectiveness of intermittent preventive treatment of malaria in infants (IPTi) for averting anaemia in Gabon: a comparison between intention to treat and according to protocol analyses. Malar J 2011; 10:305. [PMID: 22004614 PMCID: PMC3224361 DOI: 10.1186/1475-2875-10-305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Accepted: 10/17/2011] [Indexed: 11/12/2022] Open
Abstract
Background In Gabon, the impact of intermittent preventive treatment of malaria in infants (IPTi) was not statistically significant on malaria reduction, but the impact on moderate anaemia was, with some differences between the intention to treat (ITT) and the according to protocol (ATP) trial analyses. Specifically, ATP was statistically significant, while ITT analysis was borderline. The main reason for the difference between ITT and ATP populations was migration. Methods This study estimates the cost-effectiveness of IPTi on the reduction of anaemia in Gabon, comparing results of the ITT and the ATP clinical trial analyses. Threshold analysis was conducted to identify when the intervention costs and protective efficacy of IPTi for the ATP cohort equalled the ITT cost-effectiveness ratio. Results Based on IPTi intervention costs, the cost per episode of moderate anaemia averted was US$12.88 (CI 95% 4.19, 30.48) using the ITT analysis and US$11.30 (CI 95% 4.56, 26.66) using the ATP analysis. In order for the ATP results to equal the cost-effectiveness of ITT, total ATP intervention costs should rise from 118.38 to 134 US$ ATP or the protective efficacy should fall from 27% to 18.1%. The uncertainty surrounding the cost-effectiveness ratio using ITT trial results was higher than using ATP results. Conclusions Migration implies great challenges in the organization of health interventions that require repeat visits in Gabon. This was apparent in the study as the cost-effectiveness of IPTp-SP worsened when drop out from the prevention was taken into account. Despite such challenges, IPTi was both inexpensive and efficacious in averting cases of moderate anaemia in infants.
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Affiliation(s)
- Elisa Sicuri
- Barcelona Centre for International Health Research, Hospital Clínic, Universitat de Barcelona, (Rosselló 132), Barcelona (08036), Spain.
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Drake TL, Okello G, Njagi K, Halliday KE, Jukes MC, Mangham L, Brooker S. Cost analysis of school-based intermittent screening and treatment of malaria in Kenya. Malar J 2011; 10:273. [PMID: 21933376 PMCID: PMC3187739 DOI: 10.1186/1475-2875-10-273] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 09/20/2011] [Indexed: 11/15/2022] Open
Abstract
Background The control of malaria in schools is receiving increasing attention, but there remains currently no consensus as to the optimal intervention strategy. This paper analyses the costs of intermittent screening and treatment (IST) of malaria in schools, implemented as part of a cluster-randomized controlled trial on the Kenyan coast. Methods Financial and economic costs were estimated using an ingredients approach whereby all resources required in the delivery of IST are quantified and valued. Sensitivity analysis was conducted to investigate how programme variation affects costs and to identify potential cost savings in the future implementation of IST. Results The estimated financial cost of IST per child screened is US$ 6.61 (economic cost US$ 6.24). Key contributors to cost were salary costs (36%) and malaria rapid diagnostic tests (RDT) (22%). Almost half (47%) of the intervention cost comprises redeployment of existing resources including health worker time and use of hospital vehicles. Sensitivity analysis identified changes to intervention delivery that can reduce programme costs by 40%, including use of alternative RDTs and removal of supervised treatment. Cost-effectiveness is also likely to be highly sensitive to the proportion of children found to be RDT-positive. Conclusion In the current context, school-based IST is a relatively expensive malaria intervention, but reducing the complexity of delivery can result in considerable savings in the cost of intervention. (Costs are reported in US$ 2010).
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Affiliation(s)
- Thomas L Drake
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
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Dicko A, Toure SO, Traore M, Sagara I, Toure OB, Sissoko MS, Diallo AT, Rogier C, Salomon R, de Sousa A, Doumbo OK. Increase in EPI vaccines coverage after implementation of intermittent preventive treatment of malaria in infant with Sulfadoxine -pyrimethamine in the district of Kolokani, Mali: results from a cluster randomized control trial. BMC Public Health 2011; 11:573. [PMID: 21767403 PMCID: PMC3155918 DOI: 10.1186/1471-2458-11-573] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 07/18/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Even though the efficacy of Intermittent Preventive Treatment in infants (IPTi) with Sulfadoxine-Pyrimethamine (SP) against clinical disease and the absence of its interaction with routine vaccines of the Expanded Immunization Programme (EPI) have been established, there are still some concerns regarding the addition of IPTi, which may increase the work burden and disrupt the routine EPI services especially in Africa where the target immunization coverage remains to be met. However IPTi may also increase the adherence of the community to EPI services and improve EPI coverage, once the benefice of strategy is perceived. METHODS To assess the impact of IPTi implementation on the coverage of EPI vaccines, 22 health areas of the district of Kolokani were randomized at a 1:1 ratio to either receive IPTi-SP or to serve as a control. The EPI vaccines coverage was assessed using cross-sectional surveys at baseline in November 2006 and after one year of IPTi pilot-implementation in December 2007. RESULTS At baseline, the proportion of children of 9-23 months who were completely vaccinated (defined as children who received BGG, 3 doses of DTP/Polio, measles and yellow fever vaccines) was 36.7% (95% CI 25.3% -48.0%). After one year of implementation of IPTi-SP using routine health services, the proportion of children completely vaccinated rose to 53.8% in the non intervention zone and 69.5% in the IPTi intervention zone (P <0.001).The proportion of children in the target age groups who received IPTi with each of the 3 vaccinations DTP2, DTP3 and Measles, were 89.2% (95% CI 85.9%-92.0%), 91.0% (95% CI 87.6% -93.7%) and 77.4% (95% CI 70.7%-83.2%) respectively. The corresponding figures in non intervention zone were 2.3% (95% CI 0.9% -4.7%), 2.6% (95% CI 1.0% -5.6%) and 1.7% (95% CI 0.4% - 4.9%). CONCLUSION This study shows that high coverage of the IPTi can be obtained when the strategy is implemented using routine health services and implementation results in a significant increase in coverage of EPI vaccines in the district of Kolokani, Mali.
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Affiliation(s)
- Alassane Dicko
- Malaria Research and Training Center, Department of Epidemiology of Parasitic Diseases, Faculty of Medicine Pharmacy and Dentistry, University of Bamako, P.O. Box 1805 Bamako, Mali
- Department of Public Health, Faculty of Medicine Pharmacy and Dentistry, University of Bamako, P.O. Box 1805 Bamako, Mali
| | - Sidy O Toure
- Malaria Research and Training Center, Department of Epidemiology of Parasitic Diseases, Faculty of Medicine Pharmacy and Dentistry, University of Bamako, P.O. Box 1805 Bamako, Mali
| | - Mariam Traore
- Malaria Research and Training Center, Department of Epidemiology of Parasitic Diseases, Faculty of Medicine Pharmacy and Dentistry, University of Bamako, P.O. Box 1805 Bamako, Mali
| | - Issaka Sagara
- Malaria Research and Training Center, Department of Epidemiology of Parasitic Diseases, Faculty of Medicine Pharmacy and Dentistry, University of Bamako, P.O. Box 1805 Bamako, Mali
| | - Ousmane B Toure
- Malaria Research and Training Center, Department of Epidemiology of Parasitic Diseases, Faculty of Medicine Pharmacy and Dentistry, University of Bamako, P.O. Box 1805 Bamako, Mali
| | - Mahamadou S Sissoko
- Malaria Research and Training Center, Department of Epidemiology of Parasitic Diseases, Faculty of Medicine Pharmacy and Dentistry, University of Bamako, P.O. Box 1805 Bamako, Mali
| | | | - Christophe Rogier
- Institut de Recherche Biomédicale des Armées IRBA - ex-IMTSSA & UMR6236-URMITE, Allée du Médecin colonel Jamot, Parc du Pharo, BP60109, 13262 Marseille cedex 07, France
| | - Roger Salomon
- Institut de Santé Publique, d'Épidémiologie et de Développement, Université Victor Segalen Bordeaux 2, Case 11 146 Rue Léo Saignat, 33076 Bordeaux Cedex - France
| | - Alexandra de Sousa
- Special Programme for Research and Training in Tropical Diseases, World Health Organization, 20 Avenue Appia, 121 Geneva 27, Switzerland
| | - Ogobara K Doumbo
- Malaria Research and Training Center, Department of Epidemiology of Parasitic Diseases, Faculty of Medicine Pharmacy and Dentistry, University of Bamako, P.O. Box 1805 Bamako, Mali
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Cairns M, Ghani A, Okell L, Gosling R, Carneiro I, Anto F, Asoala V, Owusu-Agyei S, Greenwood B, Chandramohan D, Milligan P. Modelling the protective efficacy of alternative delivery schedules for intermittent preventive treatment of malaria in infants and children. PLoS One 2011; 6:e18947. [PMID: 21533088 PMCID: PMC3080380 DOI: 10.1371/journal.pone.0018947] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 03/24/2011] [Indexed: 11/18/2022] Open
Abstract
Background Intermittent preventive treatment in infants (IPTi) with sulfadoxine-pyrimethamine (SP) is recommended by WHO where malaria incidence in infancy is high and SP resistance is low. The current delivery strategy is via routine Expanded Program on Immunisation contacts during infancy (EPI-IPTi). However, improvements to this approach may be possible where malaria transmission is seasonal, or where the malaria burden lies mainly outside infancy. Methods and Findings A mathematical model was developed to estimate the protective efficacy (PE) of IPT against clinical malaria in children aged 2-24 months, using entomological and epidemiological data from an EPI-IPTi trial in Navrongo, Ghana to parameterise the model. The protection achieved by seasonally-targeted IPT in infants (sIPTi), seasonal IPT in children (sIPTc), and by case-management with long-acting artemisinin combination therapies (LA-ACTs) was predicted for Navrongo and for sites with different transmission intensity and seasonality. In Navrongo, the predicted PE of sIPTi was 26% by 24 months of age, compared to 16% with EPI-IPTi. sIPTc given to all children under 2 years would provide PE of 52% by 24 months of age. Seasonally-targeted IPT retained its advantages in a range of transmission patterns. Under certain circumstances, LA-ACTs for case-management may provide similar protection to EPI-IPTi. However, EPI-IPTi or sIPT combined with LA-ACTs would be substantially more protective than either strategy used alone. Conclusion Delivery of IPT to infants via the EPI is sub-optimal because individuals are not protected by IPT at the time of highest malaria risk, and because older children are not protected. Alternative delivery strategies to the EPI are needed where transmission varies seasonally or the malaria burden extends beyond infancy. Long-acting ACTs may also make important reductions in malaria incidence. However, delivery systems must be developed to ensure that both forms of chemoprevention reach the individuals who are most exposed to malaria.
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Affiliation(s)
- Matthew Cairns
- London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Ross A, Maire N, Sicuri E, Smith T, Conteh L. Determinants of the cost-effectiveness of intermittent preventive treatment for malaria in infants and children. PLoS One 2011; 6:e18391. [PMID: 21490967 PMCID: PMC3072385 DOI: 10.1371/journal.pone.0018391] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Accepted: 02/28/2011] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Trials of intermittent preventive treatment in infants (IPTi) and children (IPTc) have shown promising results in reducing malaria episodes but with varying efficacy and cost-effectiveness. The effects of different intervention and setting characteristics are not well known. We simulate the effects of the different target age groups and delivery channels, seasonal or year-round delivery, transmission intensity, seasonality, proportions of malaria fevers treated and drug characteristics. METHODS We use a dynamic, individual-based simulation model of Plasmodium falciparum malaria epidemiology, antimalarial drug action and case management to simulate DALYs averted and the cost per DALY averted by IPTi and IPTc. IPT cost components were estimated from economic studies alongside trials. RESULTS IPTi and IPTc were predicted to be cost-effective in most of the scenarios modelled. The cost-effectiveness is driven by the impact on DALYs, particularly for IPTc, and the low costs, particularly for IPTi which uses the existing delivery strategy, EPI. Cost-effectiveness was predicted to decrease with low transmission, badly timed seasonal delivery in a seasonal setting, short-acting and more expensive drugs, high frequencies of drug resistance and high levels of treatment of malaria fevers. Seasonal delivery was more cost-effective in seasonal settings, and year-round in constant transmission settings. The difference was more pronounced for IPTc than IPTi due to the different proportions of fixed costs and also different assumed drug spacing during the transmission season. The number of DALYs averted was predicted to decrease as a target five-year age-band for IPTc was shifted from children under 5 years into older ages, except at low transmission intensities. CONCLUSIONS Modelling can extend the information available by predicting impact and cost-effectiveness for scenarios, for outcomes and for multiple strategies where, for practical reasons, trials cannot be carried out. Both IPTi and IPTc are generally cost-effective but could be rendered cost-ineffective by characteristics of the setting, drug or implementation.
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Affiliation(s)
- Amanda Ross
- Swiss Tropical and Public Health Institute, Basel, Switzerland.
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Pell C, Straus L, Phuanukoonnon S, Lupiwa S, Mueller I, Senn N, Siba P, Gysels M, Pool R. Community response to intermittent preventive treatment of malaria in infants (IPTi) in Papua New Guinea. Malar J 2010; 9:369. [PMID: 21176197 PMCID: PMC3224244 DOI: 10.1186/1475-2875-9-369] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Accepted: 12/22/2010] [Indexed: 11/11/2022] Open
Abstract
Background Building on previous acceptability research undertaken in sub-Saharan Africa this article aims to investigate the acceptability of intermittent preventive treatment of malaria in infants (IPTi) in Papua New Guinea (PNG). Methods A questionnaire was administered to mothers whose infants participated in the randomised placebo controlled trial of IPTi. Mothers whose infants participated and who refused to participate in the trial, health workers, community reporters and opinion leaders were interviewed. Men and women from the local community also participated in focus group discussions. Results Respondents viewed IPTi as acceptable in light of wider concern for infant health and the advantages of trial participation. Mothers reported complying with at-home administration of IPTi due to perceived benefits of IPTi and pressure from health workers. In spite of patchy knowledge, respondents also demonstrated a demand for infant vaccinations and considered non-vaccination to be neglect. There is little evidence that IPTi has negative impacts on attitudes to EPI, EPI adherence or existing malaria prevention practices. Conclusion The degree of similarity between findings from the acceptability studies undertaken in sub-Saharan Africa and PNG allows some generalization relating to the implementation of IPTi outside of Africa: IPTi fits well with local health cultures, appears to be accepted easily and has little impact on attitudes towards EPI or malaria prevention. The study adds to the evidence indicating that IPTi could be rolled out in a range of social and cultural contexts.
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Affiliation(s)
- Christopher Pell
- Barcelona Centre for International Health Research (CRESIB), Hospital Clínic / IDIBAPS, Universitat de Barcelona, Spain
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Sicuri E, Bardají A, Nhampossa T, Maixenchs M, Nhacolo A, Nhalungo D, Alonso PL, Menéndez C. Cost-effectiveness of intermittent preventive treatment of malaria in pregnancy in southern Mozambique. PLoS One 2010; 5:e13407. [PMID: 20976217 PMCID: PMC2955525 DOI: 10.1371/journal.pone.0013407] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 09/16/2010] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Malaria in pregnancy is a public health problem for endemic countries. Economic evaluations of malaria preventive strategies in pregnancy are needed to guide health policies. METHODS AND FINDINGS This analysis was carried out in the context of a trial of malaria intermittent preventive treatment in pregnancy with sulphadoxine-pyrimethamine (IPTp-SP), where both intervention groups received an insecticide treated net through the antenatal clinic (ANC) in Mozambique. The cost-effectiveness of IPTp-SP on maternal clinical malaria and neonatal survival was estimated. Correlation and threshold analyses were undertaken to assess the main factors affecting the economic outcomes and the cut-off values beyond which the intervention is no longer cost-effective. In 2007 US$, the incremental cost-effectiveness ratio (ICER) for maternal malaria was 41.46 US$ (95% CI 20.5, 96.7) per disability-adjusted life-year (DALY) averted. The ICER per DALY averted due to the reduction in neonatal mortality was 1.08 US$ (95% CI 0.43, 3.48). The ICER including both the effect on the mother and on the newborn was 1.02 US$ (95% CI 0.42, 3.21) per DALY averted. Efficacy was the main factor affecting the economic evaluation of IPTp-SP. The intervention remained cost-effective with an increase in drug cost per dose up to 11 times in the case of maternal malaria and 183 times in the case of neonatal mortality. CONCLUSIONS IPTp-SP was highly cost-effective for both prevention of maternal malaria and reduction of neonatal mortality in Mozambique. These findings are likely to hold for other settings where IPTp-SP is implemented through ANC visits. The intervention remained cost-effective even with a significant increase in drug and other intervention costs. Improvements in the protective efficacy of the intervention would increase its cost-effectiveness. Provision of IPTp with a more effective, although more expensive drug than SP may still remain a cost-effective public health measure to prevent malaria in pregnancy. TRIAL REGISTRATION ClinicalTrials.gov NCT00209781.
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Affiliation(s)
- Elisa Sicuri
- Barcelona Centre for International Health Research (RESIB, Hospital Clínic/IDIBAPS, Universitat de Barcelona, Barcelona, Spain.
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