title: Economic evaluation of artesunate and three quinine regimens in the treatment of severe malaria in children at the Ebolowa Regional Hospital-Cameroon: a cost analysis.
abstract: BACKGROUND
  Severe malaria is a leading cause of morbidity and mortality in under-fives in sub-Saharan Africa. Recently quinine has been replaced by artesunate as the first-line drug in the treatment of severe malaria in Cameroon. Artesunate has been shown to be cost-effective in African children, but whether these findings are transferable to Cameroonian children remains to be explored.
  
  
  OBJECTIVE
  To conduct a cost-analysis of four different regimens used in the treatment from the perspective of the healthcare payer.
  
  
  METHODS
  An economic evaluation alongside a randomized comparative study was conducted in children aged 3 months to 15 years, admitted at the Ebolowa Regional Hospital with severe malaria due to Plasmodium falciparum. Patients were randomized to receive one of the four treatment alternatives. Group 1 (ARTES) received parenteral artesunate at 2.4 mg/kg at H0, H12, H24and then once daily; Group 2 (QLD) received a loading dose of quinine base at 16.6 mg/kg followed 8 h later by an 8-hourly maintenance dose of 8.3 mg/kg quinine base; Group 3 (QNLD3) received 8.3 mg/kg quinine base every 8 h, and Group 4 (QNLD2) received 12.5 mg/kg quinine base every 12 h. The main outcome measure for effectiveness of treatment was the parasite reduction rate. Based on a healthcare perspective, an evaluation of direct medical costs was done, including costs of anti-malarials, nursing care materials, adjuvant treatment, laboratory investigations, hospitalisation and professional fees. Guided by a cost minimalization approach, the relative costs of these treatment alternatives was compared and reported.
  
  
  RESULTS
  Overall cost was higher for ARTES group at $65.14 (95% CI $57.68-72.60) than for quinine groups ($52.49-$62.40), but the difference was not statistically significant. Cost of the anti-malarial drug was significantly higher for artesunate-treated patients than for quinine-treated patients, whereas cost of hospitalization was significantly lower for artesunate-treated patients than for quinine-treated patients. Incremental analysis of ARTES against QLD as a baseline resulted in an ICER of $46.8/PRR24and suggests ARTES as the most cost effective of all four treatment options.
  
  
  CONCLUSIONS
  Artesunate is a cost effective malaria treatment option relative to quinine alternatives with the lowest incremental cost per unit of effectiveness. Trial registration clinicaltrials.gov identifier: NCT02563704. Registered 19 September 2015, retrospectively registered.
authors.affiliation: Department of Paediatrics, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaoundé, Cameroon. e_makadaniel@yahoo.fr.
authors.forename: Daniel Ethe
authors.initials: DE
authors.lastname: Maka
authors.affiliation: Department of Paediatrics, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaoundé, Cameroon.|Paediatric Unit, Yaounde Gynaeco-Obstetric and Paediatric Hospital, Yaoundé, Cameroon.
authors.forename: Andreas
authors.initials: A
authors.lastname: Chiabi
authors.affiliation: Healthlogics Limited, Lagos, Nigeria.
authors.forename: Bolaji
authors.initials: B
authors.lastname: Obadeyi
authors.affiliation: Department of Paediatrics, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaoundé, Cameroon.|Paediatric Unit, Yaounde Gynaeco-Obstetric and Paediatric Hospital, Yaoundé, Cameroon.
authors.forename: Evelyn
authors.initials: E
authors.lastname: Mah
authors.affiliation: Department of Paediatrics, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaoundé, Cameroon.|Paediatric Unit, Yaounde Gynaeco-Obstetric and Paediatric Hospital, Yaoundé, Cameroon.
authors.forename: Séraphin
authors.initials: S
authors.lastname: Nguefack
authors.affiliation: Paediatric Unit, Ebolowa Regional Hospital, Ebolowa, Cameroon.
authors.forename: Pamela
authors.initials: P
authors.lastname: Nana
authors.affiliation: Department of Physiology and Biochemistry, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon.
authors.forename: Wilfred
authors.initials: W
authors.lastname: Mbacham
authors.affiliation: Department of Paediatrics, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaoundé, Cameroon.|Paediatric Unit, Yaounde Gynaeco-Obstetric and Paediatric Hospital, Yaoundé, Cameroon.
authors.forename: Elie
authors.initials: E
authors.lastname: Mbonda
mesh_terms: D000293:Adolescent; D000962:Antimalarials / Q000008:administration & dosage* / Q000191:economics*; D037621:Artemisinins / Q000008:administration & dosage* / Q000191:economics*; D000077332:Artesunate; D002163:Cameroon; D002648:Child; D002675:Child, Preschool; D003365:Costs and Cost Analysis; D005260:Female; D005102:Health Expenditures; D006761:Hospitals; D006801:Humans; D007223:Infant; D016778:Malaria, Falciparum / Q000188:drug therapy*; D008297:Male; D011803:Quinine / Q000008:administration & dosage* / Q000191:economics*
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D000077332:Artesunate; D011803:Quinine
keywords: Artesunate; Cameroon; Children; Cost; Cost-analysis; Quinine; Severe malaria