Academic journal article Bulletin of the World Health Organization

Cost-Effectiveness Analysis of Artesunate and Quinine + Tetracycline for the Treatment of Uncomplicated Falciparum Malaria in Chanthaburi, Thailand

Academic journal article Bulletin of the World Health Organization

Cost-Effectiveness Analysis of Artesunate and Quinine + Tetracycline for the Treatment of Uncomplicated Falciparum Malaria in Chanthaburi, Thailand

Article excerpt

Voir page 241 le resume en francais. En la pagina 242 figura un resumen en espanol.


Malaria is a major health problem in Thailand (1), and those who are responsible for its control and for drug policy need to address two important issues when selecting antimalarials for use in the country: the escalating problem of multidrug resistance (2) and the scarcity of funds and health personnel (3). Ideally, the aim in the choice of a drug regimen for controlling the disease is to maximize the number of malaria cases treated, with the highest degree of cost-effectiveness and without aggravating the existing problem of multidrug resistance.

The need for a cost-effectiveness analysis of the currently used and alternative antimalarials has been recognized by the policy-makers of Thailand's Malaria Control Division. One of the promising alternatives to the standard 7-day quinine + tetracycline regimen in high-resistance areas (4) is the 5-day 700-mg oral artesunate regimen, which was shown in a hospital-based study (5) to have the same curative efficacy as the former, a more rapid onset of action, and shorter parasite and fever clearance times. Hence, it has the advantage of preventing the development of severe and complicated malaria if used sufficiently early, and a higher potential for reducing mortality than quinine + tetracycline. In addition, by virtue of its milder adverse effects (5), shorter course and once-a-day dosing, the probability of noncompliance (with subsequent development of drug pressure from subtherapeutic dosing) and of amplifying multidrug-resistance should be lower. However, oral artesunate costs more and, to date, there is a need to determine its curative effectiveness and investigate whether it is more cost-effective than quinine + tetracycline. The present study was therefore conducted to compare the cost-effectiveness of the two regimens (from the providers' perspective) when they are used in the field (malaria clinic), based on their curative effectiveness.

Materials and methods

Study area

The study was conducted at a malaria clinic in Tabsai Subdistrict, Pong Nam Ron District, Chanthaburi Province, in eastern Thailand from October 1994 to August 1995. The study area lies along the Thai-Cambodian border, a well-known hard core focus for multidrug-resistant falciparum malaria in the country (2). Establishment of malaria clinics in these endemic areas, where early diagnosis and treatment are provided free of charge, is one of the major operational strategies adopted for the containment of malaria in Thailand (3). These clinics, with no doctors and services provided only by trained paramedics, play an increasingly important role in the control of malaria in the country, and take care of [is greater than] 60% of malaria cases reported by the Antimalaria Programme.

Study population

Criteria for inclusion in the study were as follows: patients aged 15-60 years attending the Tabsai malaria clinic with uncomplicated falciparum malaria (6), which was confirmed by a positive Giemsastained peripheral blood film (7). Patients with manifestations of severe and complicated malaria, pregnant women, and patients with a history of renal and/or hepatic disease or allergy to artesunate, quinine or tetracycline were excluded. The sample size was calculated with a two-tailed significance level at 5% probability and statistical power of 80%, assuming a 65% cure rate in the quinine + tetracycline group and 95% in the artesunate group. The curative efficacy of these two regimens has been reported in a hospital setting (5), but not in the field or clinic. The notoriety of quinine + tetracycline for potential noncompliance when prescribed in the field (8, 9) and the claim that noncompliance can lead to treatment failure (10) prompted us to use compliance as the surrogate index for cure. Estimates of cure rates were therefore based on compliance. …

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