Cost-Effectiveness of Malaria Diagnostic Methods in Sub-Saharan Africa in an Era of Combination therapy/Rapport Cout-Efficacite Des Methodes De Diagnotic Du Paludisme En Afrique Subsaharienne a L'heure Des polytherapies/Costoeficacia De Los Metodos De Diagnostico De la Malaria En El Africa Subsahariana En la Era del Tratamiento Combinado

By Shillcutt, Samuel; Morel, Chantal et al. | Bulletin of the World Health Organization, February 2008 | Go to article overview

Cost-Effectiveness of Malaria Diagnostic Methods in Sub-Saharan Africa in an Era of Combination therapy/Rapport Cout-Efficacite Des Methodes De Diagnotic Du Paludisme En Afrique Subsaharienne a L'heure Des polytherapies/Costoeficacia De Los Metodos De Diagnostico De la Malaria En El Africa Subsahariana En la Era del Tratamiento Combinado


Shillcutt, Samuel, Morel, Chantal, Goodman, Catherine, Coleman, Paul, Bell, David, Whitty, Christopher J. M., Mills, A., Bulletin of the World Health Organization


Introduction

The introduction of high-cost antimalarial drugs such as artemisinin-based combination therapy (ACT) is encouraging malaria-endemic countries in sub-Saharan Africa to reassess diagnostic practices. Traditional practice for outpatients has been to treat presumptively for malaria based on a history of fever, (1,2) but a significant proportion of those treated may not have parasites (over 50% in many settings) and hence waste a considerable amount of drugs. (3-6) Widespread prescription of chloroquine to patients not having malaria has been tolerated, partly because chloroquine is so cheap; however, ACT costs at least 10 times more per treatment. (7) Moreover, overdiagnosis of malaria implies under diagnosis and inappropriate treatment of non-malarial febrile illness: while a high proportion of such illnesses are self-limiting viral diseases, a significant minority, such as acute respiratory infections or bacterial meningitis, are bacterial diseases and potentially fatal. (8,9)

WHO currently makes the tentative recommendation that parasite-based diagnosis should be used in all cases of suspected malaria with the possible exception of children in high-prevalence areas and certain other situations. (10,11) However, formal analyses have not estimated the epidemiological and economic thresholds at which different diagnostic strategies are preferable. As microscopy is generally limited to larger clinics, rapid diagnostic tests (RDTs) for malaria could be considered for most patients in endemic regions. However, there is very little evidence to guide decision-makers on the relative cost-effectiveness of presumptive treatment, RDTs and microscopy across epidemiological settings.

The objective of this study is to use a decision tree model and probabilistic sensitivity analysis to estimate the relative cost-effectiveness of RDTs, presumptive treatment and field standard microscopy in different epidemiological settings of sub-Saharan Africa where Plasmodium falciparum predominates.

Methods

We developed a decision tree that begins with ambulatory patients presenting with fever to health facilities in rural sub-Saharan Africa (Fig. 1, Fig. 2, Fig. 3, Fig. 4), and proceeds through diagnosis and treatment to disease outcomes according to the sensitivity and specificity of each diagnostic strategy, the patient's age and malaria prevalence among patients. Typical facilities would include health centres and dispensaries staffed by nurses and perhaps clinical officers, and outpatient departments of district hospitals. Once given first-line treatment, patients were assumed to face the same probabilities, health outcomes and costs regardless of diagnostic method. Parameter estimates for initial diagnosis and treatment were extracted from recently published data. Parameters describing treatment seeking patterns, costs for programme implementation and secondary treatment, and duration of disease were based mainly on those used in previous models. (12,13) Expert opinion was relied on for probabilities of disease progression and mortality without appropriate treatment where reliable published data do not exist. Parameter values, sources, best estimates and probability distributions representing parameter uncertainty are available at: http://www.wpro.who.int/sites/rdt.

[FIGURE 1 OMITTED]

We assumed that health workers used the diagnostic test result in their clinical decision-making and that patients diagnosed positive for malaria received ACT and patients negative for malaria received an antibiotic such as amoxicillin. The proportion receiving antibiotics was varied in the sensitivity analysis. Best (most likely) estimates for drug efficacy were set at 85% for ACT in cases of malaria and 75% for antibiotics in bacterial disease. We assumed that antibiotics were not efficacious for malaria or viral illness, and that antimalarials did not cure bacterial disease. We assumed no coinfection between malaria and bacterial infections. …

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Cost-Effectiveness of Malaria Diagnostic Methods in Sub-Saharan Africa in an Era of Combination therapy/Rapport Cout-Efficacite Des Methodes De Diagnotic Du Paludisme En Afrique Subsaharienne a L'heure Des polytherapies/Costoeficacia De Los Metodos De Diagnostico De la Malaria En El Africa Subsahariana En la Era del Tratamiento Combinado
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