Cost-Effectiveness Analysis of Test-Based versus Presumptive Treatment of Uncomplicated Malaria in Children under Five Years in an Area of High Transmission in Central Ghana

Abstract

BackgroundThe presumptive approach of confirming malaria in health facilities leads to over-diagnosis of malaria, over use of anti-malaria drugs and the risk of drug resistance development. WHO recommends parasitological confirmation before treatment with artemisinin-based combination therapy (ACT) in all suspected malaria patients. The use of malaria rapid diagnostic tests (mRDTs) would make it possible for prescribers to diagnose malaria at point-of-care and better target the use of antimalarials. Therefore, a cost-effectiveness analysis was performed on the introduction of mRDTs for management of malaria in under-five children in a high transmission area in Ghana where presumptive diagnosis was the norm in public health centres.MethodsA cluster-randomised controlled trial where thirty-two health centres were randomised into test-based diagnosis of malaria using mRDTs (intervention) or clinical judgement (control) was used to measure the effect of mRDTs on appropriate treatment: ‘a child with a positive reference diagnosis prescribed a course of ACT or a child with a negative reference diagnosis not given an ACT’. Cost data was collected from five purposively selected health centres and used to estimate the health sector costs of performing an mRDT and treat children for malaria and other common febrile illnesses. Costs of training healthcare personnel and supervision in the study period were also collected. A sample of caregivers to children participating in the trial was interviewed about household cost incurred on transport, drugs, fees, and special food during a period of one week after the health centre visit as well as days unable to work. A decision model approach was used to calculate the incremental cost-effectiveness ratios (ICERs). Univariate and multivariate sensitivity analyses were applied to assess the robustness of ICERs.ResultsThe availability of mRDTs for malaria diagnosis resulted in fewer ACT treatments compared to the clinical judgement approach (73% versus 81%) and more children appropriately treated (70% versus 57%). The introduction of mRDT-based diagnosis would cost the Ministry of Health US$18.6 per extra appropriately treated child under five compared to clinical judgement while the ICER from a societal perspective was lower at US$11.0 per appropriately treated child. ICERs were sensitive to a decrease in adherence to negative mRDTs, malaria positivity rate and specificity of the mRDT.ConclusionThe introduction of mRDTs is likely to be considered cost-effective in this high transmission setting as this intervention increased the number of appropriately treated children at low cost.Trial RegistrationClinicalTrials.gov NCT00832754

Cost-effectiveness analysis of malaria rapid diagnostic tests: a systematic review

“…Most of the studies were conducted in Africa, except three: one in Afghanistan [29], and two in Brazil [36, 37]. The Africa-based studies were all performed in Sub-Saharan Africa (Ethiopia [32], Congo [35], Ghana [38, 40], Kenya [28], Nigeria [41], Senegal [34], Tanzania [33], Uganda [27, 30, 31]). One study targeted at all endemic countries in Sub-Saharan Africa using a simulated cohort with fever in the rural areas [39].…”

“…Eleven studies focused on suspected malaria and fever patients. Among the other four studies, two targeted at children [38, 40], one focused on the application of RDT in school students [28], and one assessed the effectiveness of RDT among healthy pregnant women [35].…”

“…Scores ranged from 7 to 23. Two studies provided a high quality of evidence with the highest score of 23 [29, 40], five had evidence of moderate quality [27, 30, 35, 36, 38], and eight had low quality with the lowest score of 7 [28, 31–34, 37, 39, 41]. The overall quality of all studies included could be seen in Fig.…”

Economic evaluation of typhoid – a review

“…Therefore a static model may suffice to evaluate the cost-effectiveness of an intervention for typhoid fever where the emphasis is on improving individual health outcomes (such as test-treat strategies) rather than benefits to the population as a result of treatment preventing onward transmission. Indeed, there are examples of studies in other infectious disease areas where static models have been used to evaluate the cost-effectiveness of rapid diagnostic testing and treatment strategies because the focus was to improve direct health outcomes without necessarily impacting disease transmission [21,22]. The goal of several recent studies in the field of typhoid economic evaluation has been to identify strategies and associated epidemiological conditions under which interventions will be costeffective.…”

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

“…Twenty-four analyses included a comparator arm of either presumptive treatment or no test.Of these, nine(46,49,50,52,76,78,79,81,82) did not include any slower testing method and therefore modelled a situation where testing was previously unavailable. In total, 11 (45.8%) economic evaluations conducted from the perspective of LMICs analysed the impact of introducing a test where current practice could result in a patient receiving no diagnostic test(49, 51-53, 71, 79, 81, 82, 89, 90, 95).…”