title: Should countries implementing an artemisinin-based combination malaria treatment policy also introduce rapid diagnostic tests?
abstract: BACKGROUND
  Within the context of increasing antimalarial costs and or decreasing malaria transmission, the importance of limiting antimalarial treatment to only those confirmed as having malaria parasites becomes paramount. This motivates for this assessment of the cost-effectiveness of routine use of rapid diagnostic tests (RDTs) as an integral part of deploying artemisinin-based combination therapies (ACTs).
  
  
  METHODS
  The costs and cost-effectiveness of using RDTs to limit the use of ACTs to those who actually have Plasmodium falciparum parasitaemia in two districts in southern Mozambique were assessed. To evaluate the potential impact of introducing definitive diagnosis using RDTs (costing $0.95), five scenarios were considered, assuming that the use of definitive diagnosis would find that between 25% and 75% of the clinically diagnosed malaria patients are confirmed to be parasitaemic. The base analysis compared two ACTs, artesunate plus sulfadoxine/pyrimethamine (AS+SP) costing $1.77 per adult treatment and artemether-lumefantrine (AL) costing $2.40 per adult treatment, as well as the option of restricting RDT use to only those older than six years. Sensitivity analyses considered lower cost ACTs and RDTs and different population age distributions.
  
  
  RESULTS
  Compared to treating patients on the basis of clinical diagnosis, the use of RDTs in all clinically diagnosed malaria cases results in cost savings only when 29% and 52% or less of all suspected malaria cases test positive for malaria and are treated with AS+SP and AL, respectively. These cut-off points increase to 41.5% (for AS+SP) and to 74% (for AL) when the use of RDTs is restricted to only those older than six years of age. When 25% of clinically diagnosed patients are RDT positive and treated using AL, there are cost savings per malaria positive patient treated of up to $2.12. When more than 29% of clinically diagnosed cases are malaria test positive, the incremental cost per malaria positive patient treated is less than US$1. When relatively less expensive ACTs are introduced (e.g. current WHO preferential price for AL of $1.44 per adult treatment), the RDT price to the healthcare provider should be $0.65 or lower for RDTs to be cost saving in populations with between 30 and 52% of clinically diagnosed malaria cases being malaria test positive.
  
  
  CONCLUSIONS
  While the use of RDTs in all suspected cases has been shown to be cost-saving when parasite prevalence among clinically diagnosed malaria cases is low to moderate, findings show that targeting RDTs at the group older than six years and treating children less than six years on the basis of clinical diagnosis is even more cost-saving. In semi-immune populations, young children carry the highest risk of severe malaria and many healthcare providers would find it harder to deny antimalarials to those who test negative in this age group.
authors.affiliation: Health Economics Unit, Department of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory, 7925 Cape Town, South Africa. charlotte@healthnetconsult.com
authors.forename: Charlotte M
authors.initials: CM
authors.lastname: Zikusooka
authors.forename: Diane
authors.initials: D
authors.lastname: McIntyre
authors.forename: Karen I
authors.initials: KI
authors.lastname: Barnes
mesh_terms: D000293:Adolescent; D000818:Animals; D037621:Artemisinins / Q000191:economics / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D003955:Diagnostic Tests, Routine / Q000191:economics*; D004983:Ethanolamines / Q000191:economics / Q000627:therapeutic use; D005449:Fluorenes / Q000191:economics / Q000627:therapeutic use; D006291:Health Policy; D006801:Humans; D007223:Infant; D000078102:Lumefantrine; D016778:Malaria, Falciparum / Q000175:diagnosis* / Q000188:drug therapy* / Q000191:economics / Q000453:epidemiology; D009073:Mozambique / Q000453:epidemiology; D018512:Parasitemia / Q000175:diagnosis*; D010963:Plasmodium falciparum / Q000302:isolation & purification; D011739:Pyrimethamine / Q000191:economics / Q000627:therapeutic use; D013413:Sulfadoxine / Q000191:economics / Q000627:therapeutic use
chemical_list: D037621:Artemisinins; D004983:Ethanolamines; D005449:Fluorenes; D013413:Sulfadoxine; C031327:artemisinin; D000078102:Lumefantrine; D011739:Pyrimethamine
references.citation: Malar J. 2007 May 16;6:58
references.pmid: 17506881
references.citation: Trans R Soc Trop Med Hyg. 1998 Jan-Feb;92(1):45-9
references.pmid: 9692150
references.citation: BMJ. 2007 Feb 24;334(7590):403
references.pmid: 17259188
references.citation: Am J Trop Med Hyg. 2007 Jun;76(6):1027-32
references.pmid: 17556606
references.citation: Nat Rev Microbiol. 2006 Sep;4(9 Suppl):S34-8
references.pmid: 17034070
references.citation: Lancet Infect Dis. 2002 Sep;2(9):564-73
references.pmid: 12206972
references.citation: Lancet. 2004 Nov 20-26;364(9448):1896-8
references.pmid: 15555670
references.citation: Trop Med Int Health. 2006 Apr;11(4):398-408
references.pmid: 16553923
references.citation: Am J Trop Med Hyg. 2007 Jan;76(1):42-7
references.pmid: 17255227
references.citation: PLoS Med. 2007 Nov 6;4(11):e309
references.pmid: 17988171
references.citation: Trop Med Int Health. 2004 Aug;9(8):846-56
references.pmid: 15303988
references.citation: JAMA. 2007 May 23;297(20):2227-31
references.pmid: 17519412
references.citation: Clin Microbiol Rev. 2002 Jan;15(1):66-78
references.pmid: 11781267
references.citation: Am J Trop Med Hyg. 2001 Dec;65(6):883-6
references.pmid: 11791992
references.citation: PLoS Med. 2005 Nov;2(11):e330
references.pmid: 16187798
references.citation: Trop Med Int Health. 2003 Oct;8(10):876-83
references.pmid: 14516298
references.citation: JAMA. 2004 Jun 2;291(21):2571-80
references.pmid: 15173148
references.citation: Am J Trop Med Hyg. 2003 Jul;69(1):26-30
references.pmid: 12932092
references.citation: Trans R Soc Trop Med Hyg. 2002 May-Jun;96(3):254-7
references.pmid: 12174772
references.citation: Lancet. 2000 Jul 22;356(9226):297-302
references.pmid: 11071185
references.citation: J Postgrad Med. 2004 Jan-Mar;50(1):35-9
references.pmid: 15047997
references.citation: Trop Med Int Health. 2004 Mar;9(3):325-9
references.pmid: 14996360
references.citation: Am J Trop Med Hyg. 2003 Apr;68(4 Suppl):50-60
references.pmid: 12749486
references.citation: Trop Med Int Health. 2004 Sep;9(9):959-66
references.pmid: 15361108
references.citation: Clin Infect Dis. 2004 Oct 15;39(8):1139-47
references.pmid: 15486837
references.citation: BMJ. 2005 Oct 1;331(7519):706-7
references.pmid: 16195260
references.citation: Trop Med Int Health. 2002 Dec;7(12):1003-8
references.pmid: 12460390