title: Cost effectiveness of seasonal intermittent preventive treatment using amodiaquine & artesunate or sulphadoxine-pyrimethamine in Ghanaian children.
abstract: BACKGROUND
  Intermittent preventive treatment for malaria in children (IPTc) involves the administration of a full course of an anti-malarial treatment to children under 5 years old at specified time points regardless of whether or not they are known to be infected, in areas where malaria transmission is seasonal. It is important to determine the costs associated with IPTc delivery via community based volunteers and also the potential savings to health care providers and caretakers due to malaria episodes averted as a consequence of IPTc.
  
  
  METHODS
  Two thousand four hundred and fifty-one children aged 3-59 months were randomly allocated to four groups to receive: three days of artesunate plus amodiaquine (AS+AQ) monthly, three days of AS+AQ bimonthly, one dose of sulphadoxine-pyrimethamine (SP) bi-monthly or placebo. This paper focuses on incremental cost effectiveness ratios (ICERs) of the three IPTc drug regimens as delivered by community based volunteers (CBV) in Hohoe, Ghana compared to current practice, i.e. case management in the absence of IPTc. Financial and economic costs from the publicly funded health system perspective are presented. Treatment costs borne by patients and their caretakers are also estimated to present societal costs. The costs and effects of IPTc during the intervention period were considered with and without a one year follow up. Probabilistic sensitivity analysis was undertaken to account for uncertainty.
  
  
  RESULTS
  Economic costs per child receiving at least the first dose of each course of IPTc show SP bimonthly, at US$8.19, is the cheapest to deliver, followed by AS+AQ bimonthly at US$10.67 and then by AS+AQ monthly at US$14.79. Training, drug delivery and supervision accounted for approximately 20-30% each of total unit costs. During the intervention period AS & AQ monthly was the most cost effective IPTc drug regimen at US$67.77 (61.71-74.75, CI 95%) per malaria case averted based on intervention costs only, US$64.93 (58.92-71.92, CI 95%) per malaria case averted once the provider cost savings are included and US$61.00 (54.98, 67.99, CI 95%) when direct household cost savings are also taken into account. SP bimonthly was US$105.35 (75.01-157.31, CI 95%) and AS & AQ bimonthly US$211.80 (127.05-399.14, CI 95%) per malaria case averted based on intervention costs only. The incidence of malaria in the post intervention period was higher in children who were <1 year old when they received AS+AQ monthly compared to the placebo group leading to higher cost effectiveness ratios when one year follow up is included. The cost per child enrolled fell considerably when modelled to district level as compared to those encountered under trial conditions.
  
  
  CONCLUSIONS
  We demonstrate how cost-effective IPTc is using three different drug regimens and the possibilities for reducing costs further if the intervention was to be scaled up to the district level. The need for effective training, drug delivery channels and supervision to support a strong network of community based volunteers is emphasised.
authors.affiliation: London School of Hygiene and Tropical Medicine, London, United Kingdom. l.conteh@imperial.ac.uk
authors.forename: Lesong
authors.initials: L
authors.lastname: Conteh
authors.forename: Edith
authors.initials: E
authors.lastname: Patouillard
authors.forename: Margaret
authors.initials: M
authors.lastname: Kweku
authors.forename: Rosa
authors.initials: R
authors.lastname: Legood
authors.forename: Brian
authors.initials: B
authors.lastname: Greenwood
authors.forename: Daniel
authors.initials: D
authors.lastname: Chandramohan
mesh_terms: D000655:Amodiaquine / Q000191:economics / Q000494:pharmacology / Q000627:therapeutic use; D000740:Anemia / Q000150:complications; D000962:Antimalarials / Q000191:economics* / Q000494:pharmacology* / Q000627:therapeutic use; D037621:Artemisinins / Q000191:economics / Q000494:pharmacology / Q000627:therapeutic use; D000077332:Artesunate; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D004338:Drug Combinations; D005869:Ghana; D006801:Humans; D007223:Infant; D008288:Malaria / Q000150:complications / Q000188:drug therapy / Q000517:prevention & control*; D011314:Preventive Health Services / Q000191:economics* / Q000379:methods*; D011739:Pyrimethamine / Q000191:economics / Q000494:pharmacology / Q000627:therapeutic use; D012621:Seasons; D013413:Sulfadoxine / Q000191:economics / Q000494:pharmacology / Q000627:therapeutic use
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D004338:Drug Combinations; D000655:Amodiaquine; C001205:fanasil, pyrimethamine drug combination; D000077332:Artesunate; D013413:Sulfadoxine; D011739:Pyrimethamine
references.citation: Cost Eff Resour Alloc. 2003 Feb 26;1(1):1
references.pmid: 12773220
references.citation: Health Policy Plan. 2008 Jan;23(1):24-35
references.pmid: 18024966
references.citation: Health Econ. 1997 Sep-Oct;6(5):511-4
references.pmid: 9353652
references.citation: Trop Med Int Health. 2005 Jun;10(6):621-2
references.pmid: 15941428
references.citation: Med Decis Making. 1985 Summer;5(2):157-77
references.pmid: 3831638
references.citation: Lancet. 2008 Sep 13;372(9642):928-39
references.pmid: 18790316
references.citation: Malar J. 2008 Oct 03;7:201
references.pmid: 18834504
references.citation: Health Policy Plan. 2005 Jan;20(1):1-13
references.pmid: 15689425
references.citation: J Health Econ. 1995 Jun;14(2):171-89
references.pmid: 10154656
references.citation: PLoS One. 2008 Jan 23;3(1):e1471
references.pmid: 18213379
references.citation: Malar J. 2008 Sep 27;7:190
references.pmid: 18822170
references.citation: Trop Med Int Health. 2004 Jan;9(1):125-32
references.pmid: 14728616
references.citation: Lancet. 2006 Feb 25;367(9511):659-67
references.pmid: 16503464
references.citation: PLoS One. 2009 Sep 28;4(9):e7164
references.pmid: 19784374
references.citation: Soc Sci Med. 1997 Sep;45(5):659-67
references.pmid: 9226789
references.citation: Malar J. 2008 Sep 30;7:196
references.pmid: 18826594
references.citation: BMC Health Serv Res. 2006 Apr 19;6:52
references.pmid: 16623946
references.citation: Lancet. 2007 Jun 23;369(9579):2121-31
references.pmid: 17586307
references.citation: Malar J. 2008 Aug 27;7:166
references.pmid: 18752675
references.citation: Malar J. 2008 Apr 29;7:73
references.pmid: 18445255
references.citation: Trop Med Int Health. 2007 Oct;12(10):1148-56
references.pmid: 17956496
references.citation: Trop Med Int Health. 2006 Jul;11(7):1003-16
references.pmid: 16827701
references.citation: Malar J. 2007 Aug 04;6:103
references.pmid: 17683584
references.citation: Bull World Health Organ. 2000;78(1):97-107
references.pmid: 10686744
references.citation: BMC Health Serv Res. 2008 Jul 31;8:165
references.pmid: 18671874
references.citation: Trans R Soc Trop Med Hyg. 1992 Nov-Dec;86(6):580-1
references.pmid: 1287903
references.citation: PLoS One. 2008;3(12):e4000
references.pmid: 19098989
references.citation: Lancet. 2000 Aug 12;356(9229):550-5
references.pmid: 10950232
references.citation: Health Policy Plan. 2005 Jan;20(1):25-34
references.pmid: 15689427
references.citation: Nature. 2005 Mar 10;434(7030):214-7
references.pmid: 15759000
references.citation: Trans R Soc Trop Med Hyg. 2008 Jul;102(7):685-93
references.pmid: 18513767
references.citation: Malar J. 2006 May 08;5:37
references.pmid: 16681856
references.citation: Health Econ. 1997 Sep-Oct;6(5):505-10
references.pmid: 9353651
references.citation: Lancet. 2009 Jan 24;373(9660):296-7
references.pmid: 19167564
references.citation: Malar J. 2008 Dec 17;7:258
references.pmid: 19091114
references.citation: Bull World Health Organ. 2007 Aug;85(8):623-30
references.pmid: 17768521
references.citation: Health Policy Plan. 2012 Jul;27(4):339-47
references.pmid: 21697246
references.citation: Trop Med Int Health. 2006 Apr;11(4):419-31
references.pmid: 16553925