Academic journal article Bulletin of the World Health Organization

Cost-Effectiveness of Parenteral Artesunate for Treating Children with Severe Malaria in Sub-Saharan Africa/Rentabilite De L'artesunate Parenteral Administre Chez Les Enfants Gravement Atteints De Paludisme En Afrique subsaharienne/Relacion Coste-Eficacia del Artesunato Para El Tratamiento De Ninos Con Malaria Grave En El Africa Subsahariana

Academic journal article Bulletin of the World Health Organization

Cost-Effectiveness of Parenteral Artesunate for Treating Children with Severe Malaria in Sub-Saharan Africa/Rentabilite De L'artesunate Parenteral Administre Chez Les Enfants Gravement Atteints De Paludisme En Afrique subsaharienne/Relacion Coste-Eficacia del Artesunato Para El Tratamiento De Ninos Con Malaria Grave En El Africa Subsahariana

Article excerpt

Introduction

Despite reported falling transmission in much of sub-Saharan Africa, (1-3) malaria remains a leading cause of inpatient admissions and mortality in paediatric wards. (4-6) The policy for first-line treatment of severe malaria is a critical factor in determining malaria mortality. The choice of treatment must ultimately be dictated not only by its efficacy, but also by the ability of frail health systems to sustain its routine use. In much of sub-Saharan Africa, per-capita health expenditure remains extremely low, with annual government health expenditure per capita averaging 34 United States dollars (US$). (7) The cost of inpatient care for a case of severe malaria has been estimated at between US$ 12 and US$ 75 and this poses a considerable burden on limited resources. (4,8)

Quinine remains the mainstay treatment of severe malaria in sub-Saharan Africa. Parenteral quinine costs as little as US$ 0.27 per ampoule (9,10) and is widely available in health facilities across the continent. It is administered either intramuscularly or intravenously, three times per day. As an infusion quinine must be given over several hours and although it is well absorbed when given intramuscularly, this route can cause abscesses and sciatic nerve damage and has been associated with tetanus. (11) Artesunate is a more expensive drug, costing around US$ 1.06 per vial. However, it is only administered once daily and can be given as an intravenous bolus injection or by intramuscular injection. It has also been shown to be safe and well tolerated. (12)

Artesunate has previously been shown not only to be more effective for the treatment of severe malaria in adults in Asia, but also highly cost-effective, with a cost per death averted of just under US$ 150. (10) Whether these findings are transferable to children in Africa, among whom the largest share of malaria mortality occurs, remains to be explored. The African Quinine Artesunate Malaria Treatment (AQUAMAT) trial is the largest hospital-based clinical trial for severe malaria to date. (13) It was carried out in 11 sites in 9 countries across sub-Saharan Africa and recruited children with severe malaria who were randomized to receive either parenteral quinine or artesunate. Parenteral treatment was completed with a course of oral artemisinin combination therapy. The primary outcome measure was in-hospital mortality, with neurological disability assessed at 28 days as an important secondary outcome.

This economic analysis was conducted alongside the AQUAMAT clinical trial to explore the cost-effectiveness of artesunate for the management of severe malaria in children in sub-Saharan Africa. The budget impact of the use of artesunate was also estimated to assess its affordability in routine practice.

Methods

Evaluation framework

A provider perspective was taken, being most relevant to the context of inpatient care. This perspective accounts for all resources used in health facilities for the treatment of severe malaria as well as for mortality and disability among the patients. The evaluation framework is a cost-effectiveness analysis using cost per disability-adjusted life year (DALY) averted and cost per death averted as measures of cost-effectiveness.

When one drug is more expensive and more effective than its comparator, the incremental cost per DALY averted is calculated. This ratio is compared with a decision threshold that is assumed to convey the maximum policy-makers are willing and able to pay for an additional DALY averted. The baseline decision thresholds used as a reference are the conservative estimates of US$ 25 and US$ 150, as suggested by the World Health Organization (WHO) and the World Bank. (14,15)

Data collection

The study was conducted in four of the 11 AQUAMAT sites. (13) Two of the selected sites, Muheza and Korogwe, were in different areas of the United Republic of Tanzania. …

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