title: Cost-effectiveness of malaria diagnosis using rapid diagnostic tests compared to microscopy or clinical symptoms alone in Afghanistan.
abstract: BACKGROUND
  Improving 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.
  
  
  METHODS
  A 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).
  
  
  RESULTS
  RDT 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.
  
  
  CONCLUSIONS
  RDTs 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.
  
  
  BACKGROUND
  The trial was registered at ClinicalTrials.gov under identifier NCT00935688.
authors.affiliation: Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. kristian.hansen@lshtm.ac.uk.
authors.forename: Kristian S
authors.initials: KS
authors.lastname: Hansen
authors.affiliation: Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. eleanor.grieve@glasgow.ac.uk.|Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK. eleanor.grieve@glasgow.ac.uk.
authors.forename: Eleanor
authors.initials: E
authors.lastname: Grieve
authors.affiliation: Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. amy.mikhail@gmail.com.|Health Protection and Research Organization, Kabul, Afghanistan. amy.mikhail@gmail.com.
authors.forename: Amy
authors.initials: A
authors.lastname: Mikhail
authors.affiliation: Health Protection and Research Organization, Kabul, Afghanistan. drmayan2006@gmail.com.
authors.forename: Ismail
authors.initials: I
authors.lastname: Mayan
authors.affiliation: Health Protection and Research Organization, Kabul, Afghanistan. nader.mohammad@googlemail.com.
authors.forename: Nader
authors.initials: N
authors.lastname: Mohammed
authors.affiliation: HealthNet-TPO, Kabul, Afghanistan. dranwarhasanzai@yahoo.com.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Anwar
authors.affiliation: Merlin, Kabul, Afghanistan. hbaktash@gmail.com.
authors.forename: Sayed H
authors.initials: SH
authors.lastname: Baktash
authors.affiliation: Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK. Tom.D@tropmedres.ac.
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Drake
authors.affiliation: Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. christopher.whitty@lshtm.ac.uk.
authors.forename: Christopher J M
authors.initials: CJ
authors.lastname: Whitty
authors.affiliation: Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. mark.rowland@lshtm.ac.uk.
authors.forename: Mark W
authors.initials: MW
authors.lastname: Rowland
authors.affiliation: Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. toby.leslie1@gmail.com.|Health Protection and Research Organization, Kabul, Afghanistan. toby.leslie1@gmail.com.
authors.forename: Toby J
authors.initials: TJ
authors.lastname: Leslie
mesh_terms: D000293:Adolescent; D000328:Adult; D000346:Afghanistan; D000368:Aged; D000818:Animals; D000962:Antimalarials / Q000627:therapeutic use; D037621:Artemisinins / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D003955:Diagnostic Tests, Routine / Q000191:economics*; D004338:Drug Combinations; D006801:Humans; D007223:Infant; D016778:Malaria, Falciparum / Q000175:diagnosis* / Q000469:parasitology / Q000635:transmission; D016780:Malaria, Vivax / Q000175:diagnosis* / Q000469:parasitology / Q000635:transmission; D008853:Microscopy / Q000191:economics*; D008875:Middle Aged; D010963:Plasmodium falciparum / Q000187:drug effects / Q000302:isolation & purification; D010966:Plasmodium vivax / Q000187:drug effects / Q000302:isolation & purification; D055815:Young Adult
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D004338:Drug Combinations; C031327:artemisinin