The cost effectiveness of changing first line therapy for uncomplicated falciparum malaria from
monotherapy (chloroquine or sulfadoxine / pyrimethamine) to combination anti-malarial therapy (CAT) at a provincial level.
The use of combination anti-malarial therapy with artesunate (CAT) has been shown to reduce clinical and
parasitological treatment failure rates1,2 and reduce gametocyte carriage 3,
4. Both of these findings, and the potential of artesunate to delay the emergence of resistance,5,6,7, could have significant economic
implications. Policy makers in a resource restricted environment are however unlikely to be able to justify the increased costs of implementing CAT as first line therapy (drug
costs, blister packaging to limit use of monotherapy, training and educational material) unless this is shown and perceived to be cost effective. This study aims to evaluate
the cost effectiveness of a provincial or national change to CAT as first line malaria therapy. |
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Policy makers in a resource restricted environment are unlikely to be able to justify the increased
costs of implementing CAT as first line therapy (drug costs, blister packaging to limit use of monotherapy, training and educational material) unless this is shown and perceived to be
cost effective. This study aims to evaluate the cost effectiveness of a provincial or national change to CAT as first line malaria therapy. |
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A change in first line treatment is usually warranted when resistance to a drug becomes unacceptably
high. Although various factors (such as efficacy, length of treatment course and safety) are taken into account when considering suitable alternatives, inevitably acquisition cost (not necessarily
cost-effectiveness) has been the most important criterion used for selecting a replacement8
. Attempts to contain costs may lead to the use of sub-optimal dosages, and less expensive (and less
effective) agents for a greater number of patients, and less inclination to provide a radical cure 8
. The increase in drug resistance in Africa has had, and will increasingly have a major impact on increased
malaria treatment costs9.
Widespread use of artesunate may potentially reduce transmission to the extent that current vector control programs could be reduced. These potential savings will however will not be included in the
analysis, as the extent to which artesunate will eliminate this need may not be evaluable over the 5 year study period.
Limited data are available on resistance growth rates, especially outside of Thailand. Chloroquine resistance has been estimated to grow at 11% per year in Africa 9
. The growth rate of SP resistance is expected to be more rapid than that of CQ12
,13. Despite widespread use in SE Asia, resistance to
artemisinin derivatives is rare14,15
. The stepwise implementation of combination therapy allows data to be
collected prospectively (and in some of the sites also retrospectively) on the growth rate of resistance.
This will allow description of growth rate of resistance to SP, and AS, over at least 5 years, and longer
where resistance data (in vivo, in vitro and PCR mutations) has been collected previously. This increase
in resistance may result in cost increases, as a result of an increase in outpatient and inpatient cases,
and higher acquisition costs of replacement antimalarials. Consequently, should CAT result in a delay in the emergence of resistance, this would potentially result in cost savings.Method References
In collaboration with:
- Prof Anne Mills, London School of Hygiene and Tropical Medicine, Health Economics and Financing Program
- Prof Di McIntyre, University of Cape Town Heath Economics Unit
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