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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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Cost effectiveness.(a) Total cases averted and total difference in costs of treatment in USD over 5 years in 492 administrative areas of Africa, comparing use of DHA–PQP with AL. (b) Incremental cost-effectiveness ratios: cost per case averted by introducing DHA–PQP as the first-line treatment instead of AL, averaged over 5 years by first administrative unit. Blue scale=areas where DHA–PQP has a positive impact on averting cases but higher overall cost than AL, red=AL dominates (averts more cases with lower costs than DHA–PQP), yellow=DHA–PQP dominates. Grey areas indicate no P. falciparum or P. falciparum slide prevalence <1% or no data.
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f5: Cost effectiveness.(a) Total cases averted and total difference in costs of treatment in USD over 5 years in 492 administrative areas of Africa, comparing use of DHA–PQP with AL. (b) Incremental cost-effectiveness ratios: cost per case averted by introducing DHA–PQP as the first-line treatment instead of AL, averaged over 5 years by first administrative unit. Blue scale=areas where DHA–PQP has a positive impact on averting cases but higher overall cost than AL, red=AL dominates (averts more cases with lower costs than DHA–PQP), yellow=DHA–PQP dominates. Grey areas indicate no P. falciparum or P. falciparum slide prevalence <1% or no data.

Mentions: We calculated the incremental cost-effectiveness ratio in each area over a 5-year period based on the predicted cumulative number of clinical malaria cases in all age groups with DHA–PQP versus AL as first-line policy. Our main cost-effectiveness analysis focusses on the scenario with current treatment access and ACT coverage in the public sector (Fig. 4a). In 64% of the population at risk, DHA–PQP improved impact on transmission but there was a higher cost of treatment due to slightly higher unit costs of DHA–PQP compared with AL (Fig. 5; Table 2). In these areas, the median incremental cost per case averted over 5 years after changing treatment policy was $1.94 (IQR: $1.20–2.75). In areas with negligible difference between the clinical incidence under the DHA–PQP scenario and the AL scenario, the cost was on average 7% less in the scenario where AL was used. In 0.4% of the population at risk, DHA–PQP reduced both the total number of cases and total costs. This occurred where the case reduction was sufficiently high and in countries where the cost of an outpatient visit is relatively high (>$7 per appointment), so that antimalarial costs constituted only a small part of the total cost of treating a malaria case. These were areas in Gabon, Equatorial Guinea and Namibia. The cost was on average 0.7% less than that in the scenario where AL was used. Where clinical incidence was higher under the DHA–PQP scenario, a DHA–PQP policy was not incrementally cost effective. In these areas, the median difference in case numbers between the AL and DHA–PQP scenarios was 1.0%, while the cost was 11% cheaper with AL than DP. In the scenario with scaled-up access to treatment (80% of cases receive an ACT), areas with >10% case reductions had an estimated cost reduction of 4% under the DHA–PQP scenario versus the AL scenario due to fewer outpatient visits.


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)

Cost effectiveness.(a) Total cases averted and total difference in costs of treatment in USD over 5 years in 492 administrative areas of Africa, comparing use of DHA–PQP with AL. (b) Incremental cost-effectiveness ratios: cost per case averted by introducing DHA–PQP as the first-line treatment instead of AL, averaged over 5 years by first administrative unit. Blue scale=areas where DHA–PQP has a positive impact on averting cases but higher overall cost than AL, red=AL dominates (averts more cases with lower costs than DHA–PQP), yellow=DHA–PQP dominates. Grey areas indicate no P. falciparum or P. falciparum slide prevalence <1% or no data.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

f5: Cost effectiveness.(a) Total cases averted and total difference in costs of treatment in USD over 5 years in 492 administrative areas of Africa, comparing use of DHA–PQP with AL. (b) Incremental cost-effectiveness ratios: cost per case averted by introducing DHA–PQP as the first-line treatment instead of AL, averaged over 5 years by first administrative unit. Blue scale=areas where DHA–PQP has a positive impact on averting cases but higher overall cost than AL, red=AL dominates (averts more cases with lower costs than DHA–PQP), yellow=DHA–PQP dominates. Grey areas indicate no P. falciparum or P. falciparum slide prevalence <1% or no data.
Mentions: We calculated the incremental cost-effectiveness ratio in each area over a 5-year period based on the predicted cumulative number of clinical malaria cases in all age groups with DHA–PQP versus AL as first-line policy. Our main cost-effectiveness analysis focusses on the scenario with current treatment access and ACT coverage in the public sector (Fig. 4a). In 64% of the population at risk, DHA–PQP improved impact on transmission but there was a higher cost of treatment due to slightly higher unit costs of DHA–PQP compared with AL (Fig. 5; Table 2). In these areas, the median incremental cost per case averted over 5 years after changing treatment policy was $1.94 (IQR: $1.20–2.75). In areas with negligible difference between the clinical incidence under the DHA–PQP scenario and the AL scenario, the cost was on average 7% less in the scenario where AL was used. In 0.4% of the population at risk, DHA–PQP reduced both the total number of cases and total costs. This occurred where the case reduction was sufficiently high and in countries where the cost of an outpatient visit is relatively high (>$7 per appointment), so that antimalarial costs constituted only a small part of the total cost of treating a malaria case. These were areas in Gabon, Equatorial Guinea and Namibia. The cost was on average 0.7% less than that in the scenario where AL was used. Where clinical incidence was higher under the DHA–PQP scenario, a DHA–PQP policy was not incrementally cost effective. In these areas, the median difference in case numbers between the AL and DHA–PQP scenarios was 1.0%, while the cost was 11% cheaper with AL than DP. In the scenario with scaled-up access to treatment (80% of cases receive an ACT), areas with >10% case reductions had an estimated cost reduction of 4% under the DHA–PQP scenario versus the AL scenario due to fewer outpatient visits.

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