Abstract
BackgroundImproving access to parasitological diagnosis of malaria is a central strategy for control and elimination of the disease. Malaria rapid diagnostic tests (RDTs) are relatively easy to perform and could be used in primary level clinics to increase coverage of diagnostics and improve treatment of malaria.MethodsA cost-effectiveness analysis was undertaken of RDT-based diagnosis in public health sector facilities in Afghanistan comparing the societal and health sector costs of RDTs versus microscopy and RDTs versus clinical diagnosis in low and moderate transmission areas. The effect measure was ‘appropriate treatment for malaria’ defined using a reference diagnosis. Effects were obtained from a recent trial of RDTs in 22 public health centres with cost data collected directly from health centres and from patients enrolled in the trial. Decision models were used to compare the cost of RDT diagnosis versus the current diagnostic method in use at the clinic per appropriately treated case (incremental cost-effectiveness ratio, ICER).ResultsRDT diagnosis of Plasmodium vivax and Plasmodium falciparum malaria in patients with uncomplicated febrile illness had higher effectiveness and lower cost compared to microscopy and was cost-effective across the moderate and low transmission settings. RDTs remained cost-effective when microscopy was used for other clinical purposes. In the low transmission setting, RDTs were much more effective than clinical diagnosis (65.2% (212/325) vs 12.5% (40/321)) but at an additional cost (ICER) of US$4.5 per appropriately treated patient including a health sector cost (ICER) of US$2.5 and household cost of US$2.0. Sensitivity analysis, which varied drug costs, indicated that RDTs would remain cost-effective if artemisinin combination therapy was used for treating both P. vivax and P. falciparum. Cost-effectiveness of microscopy relative to RDT is further reduced if the former is used exclusively for malaria diagnosis. In the health service setting of Afghanistan, RDTs are a cost-effective intervention compared to microscopy.ConclusionsRDTs remain cost-effective across a range of drug costs and if microscopy is used for a range of diagnostic services. RDTs have significant advantages over clinical diagnosis with minor increases in the cost of service provision.Trial RegistrationThe trial was registered at ClinicalTrials.gov under identifier NCT00935688.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-015-0696-1) contains supplementary material, which is available to authorized users.
Highlights
Improving access to parasitological diagnosis of malaria is a central strategy for control and elimination of the disease
In the moderate transmission eastern region, the societal cost per patient was marginally lower in the rapid diagnostic tests (RDTs) arm compared to the microscopy arm (US$9.5 versus US$9.8) but the effect in terms of appropriately treated patients was higher in the RDT arm than in the microscopy arm (83.7%, CI: (82.0%; 85.3%) versus 76.3%, CI: (74.4%; 78.2%))
Since the effect was higher and the cost was lower, diagnosis by RDT is the dominant option compared to diagnosis by microscopy from an economic perspective
Summary
Improving access to parasitological diagnosis of malaria is a central strategy for control and elimination of the disease. Improving access to parasitological malaria diagnosis is a central strategy for control and elimination of the disease and is recommended before anti-malarial treatment in all suspected malaria cases [1,2]. Diagnosis in most primary level clinics in south and west Asia relies either on symptoms and signs alone or on microscopy [3,4] Both of these methods have significant drawbacks: symptoms and signs are indistinguishable from other causes of fever [5] and cannot differentiate between species, while microscopy is often inaccurate under field conditions, hard to maintain, requires skilled staff and can suffer from a tendency by health providers to treat patients with negative test results [6,7,8,9,10]. The effect was strong for the detection and treatment of cases of P. falciparum malaria when relatively rare
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