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Contrasting benefits of different artemisinin combination therapies as first-line malaria treatments using model-based cost-effectiveness analysis.

Okell LC, Cairns M, Griffin JT, Ferguson NM, Tarning J, Jagoe G, Hugo P, Baker M, D'Alessandro U, Bousema T, Ubben D, Ghani AC - Nat Commun (2014)

Bottom Line: DHA-PQP has a modestly higher estimated impact than AL in 64% of the population at risk.Given current higher cost estimates for DHA-PQP, there is a slightly greater cost per case averted, except in areas with high, seasonally varying transmission where the impact is particularly large.We find that a locally optimized treatment policy can be highly cost effective for reducing clinical malaria burden.

View Article: PubMed Central - PubMed

Affiliation: MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College, London W2 1PG, UK.

ABSTRACT
There are currently several recommended drug regimens for uncomplicated falciparum malaria in Africa. Each has different properties that determine its impact on disease burden. Two major antimalarial policy options are artemether-lumefantrine (AL) and dihydroartemisinin-piperaquine (DHA-PQP). Clinical trial data show that DHA-PQP provides longer protection against reinfection, while AL is better at reducing patient infectiousness. Here we incorporate pharmacokinetic-pharmacodynamic factors, transmission-reducing effects and cost into a mathematical model and simulate malaria transmission and treatment in Africa, using geographically explicit data on transmission intensity and seasonality, population density, treatment access and outpatient costs. DHA-PQP has a modestly higher estimated impact than AL in 64% of the population at risk. Given current higher cost estimates for DHA-PQP, there is a slightly greater cost per case averted, except in areas with high, seasonally varying transmission where the impact is particularly large. We find that a locally optimized treatment policy can be highly cost effective for reducing clinical malaria burden.

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Related in: MedlinePlus

Africa-wide simulations.Estimated impact of using DHA–PQP versus AL as the first-line treatment by first administrative unit in malaria-endemic areas of Africa. Cumulative numbers of clinical episodes prevented 5 years after changing treatment policy per 1,000 individuals of all ages, under different coverage scenarios: (a) current ACT treatment rates in the public sector only, (b) current ACT treatment rates in the public and private sector, (c) current antimalarial treatment rates with scaled-up ACT coverage to 100% and (d) scaled-up treatment access—80% of clinical malaria cases receive ACT. Grey areas indicate no P. falciparum or a slide prevalence <1% or no data.
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f4: Africa-wide simulations.Estimated impact of using DHA–PQP versus AL as the first-line treatment by first administrative unit in malaria-endemic areas of Africa. Cumulative numbers of clinical episodes prevented 5 years after changing treatment policy per 1,000 individuals of all ages, under different coverage scenarios: (a) current ACT treatment rates in the public sector only, (b) current ACT treatment rates in the public and private sector, (c) current antimalarial treatment rates with scaled-up ACT coverage to 100% and (d) scaled-up treatment access—80% of clinical malaria cases receive ACT. Grey areas indicate no P. falciparum or a slide prevalence <1% or no data.

Mentions: Assuming that the proportion of cases receiving an antimalarial and ACT coverage remains at their current levels27 (Fig. 4a) and that treatment policy change would only affect the public sector, DHA–PQP had a modestly higher impact than AL in 64% of the population at risk. In these populations, a median of 26 cases per 1,000 people (interquartile range (IQR): 15–43) were averted in the 5 years after the policy change compared with the scenario of using AL. Areas where DHA–PQP was predicted to have the highest impact were those with high levels of transmission, large seasonal variation in transmission and with reasonable ACT coverage in the public sector; these included Burkina Faso, southern Mali and northeast Mozambique, where the number of cases averted was up to 100 per 1,000 people over 5 years. In a further 32% of the population at risk, there was negligible difference (<0.5%) between the AL and DHA–PQP scenarios. In some areas, this was simply due to low recorded ACT coverage. In other areas such as the highlands of East Africa, there was less impact due to low malaria transmission, meaning that there is less benefit of prophylaxis. In 4% of the population at risk, AL had a slightly better impact than DHA–PQP; these were areas with low endemicity, where there is almost no benefit of prophylaxis, but there is some benefit of the greater gametocytocidal action of AL. The difference was small, with a median of 2.7 (IQR: 1.8–6.3) fewer cases per 1,000 over 5 years in the AL compared with DHA–PQP scenario. We also ran a subgroup analysis for countries that currently use AL as a first-line treatment28. An estimated 7.3 million clinical cases would be averted over 5 years by switching to DHA–PQP, or 0.9% of total cases (IQR across areas: 0.4–1.7%). This assumes that all ACTs used were either AL or DHA–PQP.


Contrasting benefits of different artemisinin combination therapies as first-line malaria treatments using model-based cost-effectiveness analysis.

Okell LC, Cairns M, Griffin JT, Ferguson NM, Tarning J, Jagoe G, Hugo P, Baker M, D'Alessandro U, Bousema T, Ubben D, Ghani AC - Nat Commun (2014)

Africa-wide simulations.Estimated impact of using DHA–PQP versus AL as the first-line treatment by first administrative unit in malaria-endemic areas of Africa. Cumulative numbers of clinical episodes prevented 5 years after changing treatment policy per 1,000 individuals of all ages, under different coverage scenarios: (a) current ACT treatment rates in the public sector only, (b) current ACT treatment rates in the public and private sector, (c) current antimalarial treatment rates with scaled-up ACT coverage to 100% and (d) scaled-up treatment access—80% of clinical malaria cases receive ACT. Grey areas indicate no P. falciparum or a slide prevalence <1% or no data.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4263185&req=5

f4: Africa-wide simulations.Estimated impact of using DHA–PQP versus AL as the first-line treatment by first administrative unit in malaria-endemic areas of Africa. Cumulative numbers of clinical episodes prevented 5 years after changing treatment policy per 1,000 individuals of all ages, under different coverage scenarios: (a) current ACT treatment rates in the public sector only, (b) current ACT treatment rates in the public and private sector, (c) current antimalarial treatment rates with scaled-up ACT coverage to 100% and (d) scaled-up treatment access—80% of clinical malaria cases receive ACT. Grey areas indicate no P. falciparum or a slide prevalence <1% or no data.
Mentions: Assuming that the proportion of cases receiving an antimalarial and ACT coverage remains at their current levels27 (Fig. 4a) and that treatment policy change would only affect the public sector, DHA–PQP had a modestly higher impact than AL in 64% of the population at risk. In these populations, a median of 26 cases per 1,000 people (interquartile range (IQR): 15–43) were averted in the 5 years after the policy change compared with the scenario of using AL. Areas where DHA–PQP was predicted to have the highest impact were those with high levels of transmission, large seasonal variation in transmission and with reasonable ACT coverage in the public sector; these included Burkina Faso, southern Mali and northeast Mozambique, where the number of cases averted was up to 100 per 1,000 people over 5 years. In a further 32% of the population at risk, there was negligible difference (<0.5%) between the AL and DHA–PQP scenarios. In some areas, this was simply due to low recorded ACT coverage. In other areas such as the highlands of East Africa, there was less impact due to low malaria transmission, meaning that there is less benefit of prophylaxis. In 4% of the population at risk, AL had a slightly better impact than DHA–PQP; these were areas with low endemicity, where there is almost no benefit of prophylaxis, but there is some benefit of the greater gametocytocidal action of AL. The difference was small, with a median of 2.7 (IQR: 1.8–6.3) fewer cases per 1,000 over 5 years in the AL compared with DHA–PQP scenario. We also ran a subgroup analysis for countries that currently use AL as a first-line treatment28. An estimated 7.3 million clinical cases would be averted over 5 years by switching to DHA–PQP, or 0.9% of total cases (IQR across areas: 0.4–1.7%). This assumes that all ACTs used were either AL or DHA–PQP.

Bottom Line: DHA-PQP has a modestly higher estimated impact than AL in 64% of the population at risk.Given current higher cost estimates for DHA-PQP, there is a slightly greater cost per case averted, except in areas with high, seasonally varying transmission where the impact is particularly large.We find that a locally optimized treatment policy can be highly cost effective for reducing clinical malaria burden.

View Article: PubMed Central - PubMed

Affiliation: MRC Centre for Outbreak Analysis and Modelling, Department of Infectious Disease Epidemiology, Imperial College, London W2 1PG, UK.

ABSTRACT
There are currently several recommended drug regimens for uncomplicated falciparum malaria in Africa. Each has different properties that determine its impact on disease burden. Two major antimalarial policy options are artemether-lumefantrine (AL) and dihydroartemisinin-piperaquine (DHA-PQP). Clinical trial data show that DHA-PQP provides longer protection against reinfection, while AL is better at reducing patient infectiousness. Here we incorporate pharmacokinetic-pharmacodynamic factors, transmission-reducing effects and cost into a mathematical model and simulate malaria transmission and treatment in Africa, using geographically explicit data on transmission intensity and seasonality, population density, treatment access and outpatient costs. DHA-PQP has a modestly higher estimated impact than AL in 64% of the population at risk. Given current higher cost estimates for DHA-PQP, there is a slightly greater cost per case averted, except in areas with high, seasonally varying transmission where the impact is particularly large. We find that a locally optimized treatment policy can be highly cost effective for reducing clinical malaria burden.

Show MeSH
Related in: MedlinePlus