Abstract
BackgroundIntermittent preventive treatment in infants (IPTi) has been shown to decrease clinical malaria by approximately 30% in the first year of life and is a promising malaria control strategy for Sub-Saharan Africa which can be delivered alongside the Expanded Programme on Immunisation (EPI). To date, there have been limited data on the cost-effectiveness of this strategy using sulfadoxine pyrimethamine (SP) and no published data on cost-effectiveness using other antimalarials.MethodsWe analysed data from 5 countries in sub-Saharan Africa using a total of 5 different IPTi drug regimens; SP, mefloquine (MQ), 3 days of chlorproguanil-dapsone (CD), SP plus 3 days of artesunate (SP-AS3) and 3 days of amodiaquine-artesunate (AQ3-AS3).The cost per malaria episode averted and cost per Disability-Adjusted Life-Year (DALY) averted were modeled using both trial specific protective efficacy (PE) for all IPTi drugs and a pooled PE for IPTi with SP, malaria incidence, an estimated malaria case fatality rate of 1.57%, IPTi delivery costs and country specific provider and household malaria treatment costs.FindingsIn sites where IPTi had a significant effect on reducing malaria, the cost per episode averted for IPTi-SP was very low, USD 1.36–4.03 based on trial specific data and USD 0.68–2.27 based on the pooled analysis. For IPTi using alternative antimalarials, the lowest cost per case averted was for AQ3-AS3 in western Kenya (USD 4.62) and the highest was for MQ in Korowge, Tanzania (USD 18.56). Where efficacious, based only on intervention costs, IPTi was shown to be cost effective in all the sites and highly cost-effective in all but one of the sites, ranging from USD 2.90 (Ifakara, Tanzania with SP) to USD 39.63 (Korogwe, Tanzania with MQ) per DALY averted. In addition, IPTi reduced health system costs and showed significant savings to households from malaria cases averted. A threshold analysis showed that there is room for the IPTi-efficacy to fall and still remain highly cost effective in all sites where IPTi had a statistically significant effect on clinical malaria.ConclusionsIPTi delivered alongside the EPI is a highly cost effective intervention against clinical malaria with a range of drugs in a range of malaria transmission settings. Where IPTi did not have a statistically significant impact on malaria, generally in low transmission sites, it was not cost effective.
Highlights
Malaria continues to devastate lives: 247 million malaria cases were reported among 3.3 billion people at risk in 2006 mostly in sub-Saharan Africa, and mostly in children under five [1]
IPTi delivered alongside the Expanded Programme on Immunisation (EPI) is a highly cost effective intervention against clinical malaria with a range of drugs in a range of malaria transmission settings
We report on the cost-effectiveness of IPTi across all IPTi clinical trial study sites in sub-Saharan Africa, spanning nine sites in five countries using five different drug regimens
Summary
Malaria continues to devastate lives: 247 million malaria cases were reported among 3.3 billion people at risk in 2006 mostly in sub-Saharan Africa, and mostly in children under five [1]. A pooled analysis of data from 6 completed trials of IPTi with sulfadoxine-pyrimethamine (SP) demonstrated 30% (20%; 39%) protective efficacy (PE) against clinical malaria, 38% (13%; 56%) PE against hospitalisations with malaria parasites, 23% (10%; 34%) PE against all-cause hospital admissions and 21% (8%; 33%) PE against anaemia in the first year of life[4]. In northern Tanzania, IPTi with mefloquine (MQ) was shown to reduce episodes of malaria in infants in a moderate transmission setting (PE 38%)[5], but had no protective effect against other outcomes including anaemia and hospital admission. Intermittent preventive treatment in infants (IPTi) has been shown to decrease clinical malaria by approximately 30% in the first year of life and is a promising malaria control strategy for Sub-Saharan Africa which can be delivered alongside the Expanded Programme on Immunisation (EPI). There have been limited data on the cost-effectiveness of this strategy using sulfadoxine pyrimethamine (SP) and no published data on cost-effectiveness using other antimalarials
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