Abstract
BackgroundTrials of intermittent preventive treatment in infants (IPTi) and children (IPTc) have shown promising results in reducing malaria episodes but with varying efficacy and cost-effectiveness. The effects of different intervention and setting characteristics are not well known. We simulate the effects of the different target age groups and delivery channels, seasonal or year-round delivery, transmission intensity, seasonality, proportions of malaria fevers treated and drug characteristics.MethodsWe use a dynamic, individual-based simulation model of Plasmodium falciparum malaria epidemiology, antimalarial drug action and case management to simulate DALYs averted and the cost per DALY averted by IPTi and IPTc. IPT cost components were estimated from economic studies alongside trials.ResultsIPTi and IPTc were predicted to be cost-effective in most of the scenarios modelled. The cost-effectiveness is driven by the impact on DALYs, particularly for IPTc, and the low costs, particularly for IPTi which uses the existing delivery strategy, EPI. Cost-effectiveness was predicted to decrease with low transmission, badly timed seasonal delivery in a seasonal setting, short-acting and more expensive drugs, high frequencies of drug resistance and high levels of treatment of malaria fevers. Seasonal delivery was more cost-effective in seasonal settings, and year-round in constant transmission settings. The difference was more pronounced for IPTc than IPTi due to the different proportions of fixed costs and also different assumed drug spacing during the transmission season. The number of DALYs averted was predicted to decrease as a target five-year age-band for IPTc was shifted from children under 5 years into older ages, except at low transmission intensities.ConclusionsModelling can extend the information available by predicting impact and cost-effectiveness for scenarios, for outcomes and for multiple strategies where, for practical reasons, trials cannot be carried out. Both IPTi and IPTc are generally cost-effective but could be rendered cost-ineffective by characteristics of the setting, drug or implementation.
Highlights
An estimated 250 million episodes of malaria led to nearly one million deaths in 2008, the brunt of which was borne by young children and infants in sub-Saharan Africa [1]
We simulate two contrasting seasonal patterns and two IPT drugs (SP and ASAQ). These four factors have two levels each making a set of 16 baseline intervention scenarios (Table 1). For each of these scenarios, we investigated the impact of varying levels of drug resistance, transmission intensity, the timing of seasonal implementation and the proportion of malaria fevers which are effectively treated (Table 2)
In the constant transmission setting (Figure 2 top row), year-round delivery averts a greater number of disability adjusted life years (DALYs) than seasonal delivery for both IPTi and IPTc (Figure 2 a and c)
Summary
An estimated 250 million episodes of malaria led to nearly one million deaths in 2008, the brunt of which was borne by young children and infants in sub-Saharan Africa [1]. Intermittent preventive treatment in infants (IPTi) and children (IPTc) have received attention in recent years as potential interventions to reduce malaria morbidity and mortality. Both follow the same strategy: to deliver a full course of an anti-malarial treatment to a population at risk at specified time points whether or not they are known to be infected [8,9]. We simulate the effects of the different target age groups and delivery channels, seasonal or year-round delivery, transmission intensity, seasonality, proportions of malaria fevers treated and drug characteristics
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