Cost-effectiveness of malaria microscopy and rapid diagnostic tests versus presumptive diagnosis: implications for malaria control in Uganda

Abstract

BackgroundCurrent Uganda National Malaria treatment guidelines recommend parasitological confirmation either by microscopy or rapid diagnostic test (RDT) before treatment with artemether-lumefantrine (AL). However, the cost-effectiveness of these strategies has not been assessed at rural operational primary care centres.MethodsThree health centres (HCs) were randomized to three diagnostic arms (microscopy, RDT and presumptive diagnosis) in a district of low and another of high malaria transmission intensities in Uganda. Some 22,052 patients presenting with fever at outpatients departments were enrolled from March 2010 to February 2011. Of these, a random sample of 1,627 was selected to measure additional socio-economic characteristics. Costing was performed following the standard step-down cost allocation and the ingredients approach. Effectiveness was measured as the number and proportion of patients correctly diagnosed and treated. Incremental Cost-Effectiveness Ratios (ICERs) were estimated from the societal perspective (http://Clinicaltrials.gov, NCT00565071).ResultsOverall RDT was most cost-effective with lowest ICER US$5.0 compared to microscopy US$9.61 per case correctly diagnosed and treated. In the high transmission setting, ICER was US$4.38 for RDT and US$12.98 for microscopy. The corresponding ICERs in the low transmission setting were US$5.85 and US$7.63 respectively. The difference in ICERs between RDT and microscopy was greater in the high transmission area (US$8.9) than in low transmission setting (US$1.78). At a willingness to pay of US$2.8, RDT remained cost effective up to a threshold value of the cost of treatment of US$4.7.ConclusionRDT was cost effective in both low and high transmission settings. With a global campaign to reduce the costs of AL and RDT, the Malaria Control Programme and stakeholders need a strategy for malaria diagnosis because as the cost of AL decreases, presumptive treatment is likely to become more attractive.

Cost and Predictors of Care-Seeking Behaviors Among Caregivers of Febrile Children—Uganda, 2009

“…Ideally, diagnostic testing for malaria, which has been previously shown to be cost-effective in Uganda and elsewhere in sub-Saharan Africa, will result in less presumptive therapy. 35,36 Regardless of government interventions, the majority of caregivers incurred costs to care for their febrile child. Although total expenditures were greater among households belonging to higher wealth quintiles, expenditures relative to household income (which was not assessed in this study) were likely higher among households in lower wealth quintiles.…”

Accuracy of Two Malaria Rapid Diagnostic Tests (RDTS) for Initial Diagnosis and Treatment Monitoring in a High Transmission Setting in Uganda

“…For example, in high transmission areas, some studies have found RDTs to be cost-effective compared with microscopy and presumptive treatment of malaria. 24 However, among children 5 years of age in high transmission settings, some investigators suggest that presumptive treatment of malaria may be more cost effective than RDTs given the high prevalence of malaria in this age group. 25 Economic factors may be weighed alongside other potential benefits of RDT use in decision-making for given regions.…”

Comparative Assessment of Microscopy and Rapid Diagnostic Test (RDT) as Malaria Diagnostic Tools

“…Its implementation has been reported to be cost effective (Batwala et al, 2011), cause significant reduction in referrals and in patient's length of hospital stay (Boyce et al, 2015). Rapid diagnostic test is a device that detects malaria antigen in a small amount of blood, usually 5-15 µL, by immunochromatographic assay with monoclonal antibodies directed against the target parasite antigen and impregnated on a test strip (Wongsrichanalai et al, 2007).…”