The economics of malaria control and elimination: a systematic review

Host-Pathogen Interaction: Biology and Public Health

Interactions between host and pathogenic microorganisms are common in nature and have a significant impact on host health, often leading to several types of infections. These interactions have evolved as a result of the ongoing battle between the host's defense mechanisms and the pathogens' invasion strategies. In this chapter, we will explore the evolution of host-pathogen interactions, explore their molecular mechanisms, examine the different stages of interaction, and discuss the development of pharmacological treatments. Understanding these interactions is crucial for improving public health, as it enables us to develop effective strategies to prevent and control infectious diseases. By gaining insights into the intricate dynamics between pathogens and their hosts, we can work towards reducing the burden of such diseases on society.

Targeted malaria elimination interventions reduce Plasmodium falciparum infections up to 3 kilometers away

Malaria elimination interventions in low-transmission settings aim to extinguish hot spots and prevent transmission to nearby areas. In malaria elimination settings, the World Health Organization recommends reactive, focal interventions targeted to the area near malaria cases shortly after they are detected. A key question is whether these interventions reduce transmission to nearby uninfected or asymptomatic individuals who did not receive interventions. Here, we measured direct effects (among intervention recipients) and spillover effects (among non-recipients) of reactive, focal interventions delivered within 500m of confirmed malaria index cases in a cluster-randomized trial in Namibia. The trial delivered malaria chemoprevention (artemether lumefantrine) and vector control (indoor residual spraying with Actellic) separately and in combination using a factorial design. We compared incidence, infection prevalence, and seroprevalence between study arms among intervention recipients (direct effects) and non-recipients (spillover effects) up to 3 km away from index cases. We calculated incremental cost-effectiveness ratios accounting for spillover effects. The combined chemoprevention and vector control intervention produced direct effects and spillover effects. In the primary analysis among non-recipients within 1 km from index cases, the combined intervention reduced malaria incidence by 43% (95% CI 20%, 59%). In secondary analyses among non-recipients 500m-3 km from interventions, the combined intervention reduced infection by 79% (6%, 95%) and seroprevalence 34% (20%, 45%). Accounting for spillover effects increased the cost-effectiveness of the combined intervention by 37%. Our findings provide the first evidence that targeting hot spots with combined chemoprevention and vector control interventions can indirectly benefit non-recipients up to 3 km away.

The Macroeconomic Impact of Increasing Investments in Malaria Control in 26 High Malaria Burden Countries: An Application of the Updated EPIC Model

BACKGROUND

Malaria remains a major public health problem. While globally malaria mortality affects predominantly young children, clinical malaria affects all age groups throughout life. Malaria not only threatens health but also child education and adult productivity while burdening government budgets and economic development. Increased investments in malaria control can contribute to reduce this burden but have an opportunity cost for the economy. Quantifying the net economic value of investing in malaria can encourage political and financial commitment.

METHODS

We adapted an existing macroeconomic model to simulate the effects of reducing malaria on the gross domestic product (GDP) of 26 high burden countries while accounting for the opportunity costs of increased investments in malaria. We compared two scenarios differing in their level of malaria investment and associated burden reduction: sustaining malaria control at 2015 intervention coverage levels, time at which coverage levels reached their historic peak and scaling-up coverage to reach the 2030 global burden reduction targets. We incorporated the effects that reduced malaria in children and young adolescents may have on the productivity of working adults and on the future size of the labour force augmented by educational returns, skills, and experience. We calibrated the model using estimates from linked epidemiologic and costing models on these same scenarios and from published country-specific macroeconomic data.

RESULTS

Scaling-up malaria control could produce a dividend of US$ 152 billion in the modelled countries, equivalent to 0.17% of total GDP projected over the study period across the 26 countries. Assuming a larger share of malaria investments is paid out from domestic savings, the dividend would be smaller but still significant, ranging between 0.10% and 0.14% of total projected GDP. Annual GDP gains were estimated to increase over time. Lower income and higher burden countries would experience higher gains.

CONCLUSION

Intensified malaria control can produce a multiplied return despite the opportunity cost of greater investments.

Achieving malaria testing and treatment targets for children under five in Mozambique: a cost-effectiveness analysis

Background

The entire population of Mozambique is at risk for malaria, which remains one of the leading causes of death. The 2017–2022 National Malaria Strategic Plan focuses on reducing malaria morbidity and mortality in high- and low-transmission areas. This study aimed to estimate the costs and health benefits of six variations of the World Health Organization’s “test-and-treat” strategy among children under five.

Methods

A decision tree model was developed that estimates the costs and health outcomes for children under five. Data on probabilities, costs, weights for disability-adjusted life years (DALYs), and quality-adjusted life years (QALYs) were based on peer-reviewed, grey literature, and primary data analysis of the 2018 Malaria Indicator Survey. Six scenarios were compared to the status quo and calculated the incremental cost-effectiveness ratio (ICER) in terms of cost per QALY gained, DALY averted, and life saved. Deterministic and probabilistic sensitivity analyses were conducted to understand the effect of parameter uncertainty on the findings.

Results

In the base case, reaching the target of 100% testing with rapid diagnostic tests (RDTs; Scenario 1) is more cost-effective than improving the testing rate alone by 10% (Scenario 2). Achieving a 100% (Scenario 3) or a 10% increase in treatment rate (Scenario 4) have ICERs that are lower than Scenarios 1 and 2. Both Scenarios 5 and 6, which represent combinations of Scenarios 1–4, have lower ICERs than their constituent strategies on their own, which suggests that improvements in treatment are more cost-effective than improvements in testing alone. These results held when DALYs averted or lives saved were used as health outcomes. Deterministic and probabilistic sensitivity analyses revealed that the cost-effectiveness of Scenarios 1–6 are subject sensitive to parameter uncertainty, though Scenarios 4 and 5 are the optimal choice when DALYs averted or QALYs gained were used as the measure of health outcomes across all cost-effectiveness thresholds.

Conclusions

Improving testing rates alone among children at risk for malaria has the potential to improve health but may not be the most efficient use of limited resources. Instead, small or large improvements in treatment, whether alone or in conjunction with improvements in testing, are the most cost-effective strategies for children under five in Mozambique.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04354-9.

The economic burden of malaria: a systematic review

Background

Quantifying disease costs is critical for policymakers to set priorities, allocate resources, select control and prevention strategies, and evaluate the cost-effectiveness of interventions. Although malaria carries a very large disease burden, the availability of comprehensive and comparable estimates of malaria costs across endemic countries is scarce.

Methods

A literature review to summarize methodologies utilized to estimate malaria treatment costs was conducted to identify gaps in knowledge.

Results

Only 45 publications met the inclusion criteria. They utilize different methods, include distinct cost components, have varied geographical coverage (a country vs a city), include different periods in the analysis, and focus on specific parasite types or population groups (e.g., pregnant women).

Conclusions

Cost estimates currently available are not comparable, hindering broad statements on the costs of malaria, and constraining advocacy efforts towards investment in malaria control and elimination, particularly with the finance and development sectors of the government.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04303-6.

Sustaining communicable disease elimination efforts in the Americas in the wake of COVID-19

The COVID-19 pandemic has disrupted implementation of health interventions and set back priority programs aiming to control and eliminate communicable diseases. At the same time, the pandemic has opened up opportunities to expedite innovations in health service delivery to increase effectiveness and position health on the development and political agendas of leaders and policy makers. In this context, we present an integrated, sustainable approach to accelerate elimination of more than 35 communicable diseases and related conditions in the region of the Americas. The Elimination Initiative promotes a life-course, person-centred approach based on four dimensions - preventing new infections, ending mortality and morbidity, and preventing disability - and four critical lines of action including strengthening health systems integration and service delivery, strengthening health surveillance and information systems, addressing environmental and social determinants of health, and furthering governance, stewardship, and finance. We present key actions and operational considerations according to each line of action that countries can take advantage of to further advance disease elimination in the region.

Prediction of malaria using deep learning models: A case study on city clusters in the state of Amazonas, Brazil, from 2003 to 2018

Background:

Malaria is curable. Nonetheless, over 229 million cases of malaria were recorded in 2019, along with 409,000 deaths. Although over 42 million Brazilians are at risk of contracting malaria, 99% percent of all malaria cases in Brazil are located in or around the Amazon rainforest. Despite declining cases and deaths, malaria remains a major public health issue in Brazil. Accurate spatiotemporal prediction of malaria propagation may enable improved resource allocation to support efforts to eradicate the disease.

Methods:

In response to calls for novel research on malaria elimination strategies that suit local conditions, in this study, we propose machine learning (ML) and deep learning (DL) models to predict the probability of malaria cases in the state of Amazonas. Using a dataset of approximately 6 million records (January 2003 to December 2018), we applied k-means clustering to group cities based on their similarity of malaria incidence. We evaluated random forest, long-short term memory (LSTM) and dated recurrent unit (GRU) models and compared their performance.

Results:

The LSTM architecture achieved better performance in clusters with less variability in the number of cases, whereas the GRU presents better results in clusters with high variability. Although Diebold-Mariano testing suggested that both the LSTM and GRU performed comparably, GRU can be trained significantly faster, which could prove advantageous in practice.

Conclusions:

All models showed satisfactory accuracy and strong performance in predicting new cases of malaria, and each could serve as a supplemental tool to support regional policies and strategies.

Malaria elimination does not cost more than malaria control: Sri Lanka a case in point

Background

Malaria was endemic in Sri Lanka for centuries and was eliminated in 2012. It is widely assumed that the costs of elimination are generally greater than that of control. The costs of malaria elimination in Sri Lanka with that of malaria control in the past using periods in which starting transmission dynamics were similar were compared.

Methods

The expenditure of the Anti-Malaria Campaign (AMC), total and by budget category, during 2002–2010 is compared with that of malaria control during the period 1980–1989, using regression analyses and the Mann Whitney U statistic.

Results

The expenditure on malaria control and malaria elimination was similar ranging from 21 to 45 million USD per year when adjusted for inflation. In both periods, external funding for the malaria progamme constituted around 24% of the total budget; during the control phase in the 1980s, external funds came from bilateral agencies and were disbursed in accordance with government budget guidelines. In the elimination phase in the 2000s, most of external funding was from the Global Fund and had flexibility of disbursement. In the 1980s, most funds were expended on commodities—insecticides, diagnostics and medicines and their delivery; in the elimination phase, they were spent on programme management, human resources, technical assistance and monitoring and evaluation; monitoring and evaluation was not a budget line in the 1980s. Although the cost per case of malaria was considerably higher during the elimination phase than in the control phase, expenditure was not on individual cases but on general systems strengthening.

Conclusion

Malaria elimination in Southeast Asia may not require more funding than malaria control. But sustained funding for an agile programme with flexibility in fund utilization and improved efficiencies in programme management with stringent monitoring and evaluation appears to be critically important.

Malaria vaccine: The lasting solution to malaria burden in Africa

Malaria is one of the deadliest infectious diseases in Africa. Many measures have been taken over the past few years to reduce the burden of malaria on public health following the recommendation of WHO, still, malaria has continued to rake devastation in Africa. Combating malaria in Africa has grown into an international concern. The eradication of malaia is a long-standing goal of public health initiatives globally. The development of vaccines will go a long way to provide the required immunity needed for the people living with malaria or vulnerable to malaria. It is imperative that a vaccine should be produced and rolled out for use, especially during the time of the COVID-19 pandemic when attention is given to mitigating the impact of the pandemic on public health. The malaria vaccine will reduce the number of hospital admission for malaria illness among children and other age groups. Africa will need to build strong innovations to overcome country-specific challenges in vaccination drive, human resources, and supply chain management. Accelerating education, sensitization, diagnosis, and eradication through joint efforts of the government, healthcare professionals and general population will help to prevent the dual synchronous epidemic of COVID-19 and Malaria in Africa.

Using donor funding to catalyse investment in malaria prevention in Ghana: an analysis of the potential impact on public and private sector expenditure

Background

An estimated 1.5 billion malaria cases and 7.6 million malaria deaths have been averted globally since 2000; long-lasting insecticidal nets (LLINs) have contributed an estimated 68% of this reduction. Insufficient funding at the international and domestic levels poses a significant threat to future progress and there is growing emphasis on the need for enhanced domestic resource mobilization. The Private Sector Malaria Prevention (PSMP) project was a 3-year intervention to catalyse private sector investment in malaria prevention in Ghana.

Methods

To assess value for money of the intervention, non-donor expenditure in the 5 years post-project catalysed by the initial donor investment was predicted. Non-donor expenditure catalysed by this investment included: workplace partner costs of malaria prevention activities; household costs in purchasing LLINs from retail outlets; domestic resource mobilization (public sector financing and private investors). Annual ratios of projected non-donor expenditure to annualized donor costs were calculated for the 5 years post-project. Alternative scenarios were constructed to explore uncertainty around future consequences of the intervention.

Results

The total donor financial cost of the 3-year PSMP project was USD 4,418,996. The average annual economic donor cost per LLIN distributed through retail sector and workplace partners was USD 21.17 and USD 7.55, respectively. Taking a 5-year post-project time horizon, the annualized donor investment costs were USD 735,805. In the best-case scenario, each USD of annualized donor investment led to USD 4.82 in annual projected non-donor expenditure by the fifth-year post-project. With increasingly conservative assumptions around the project consequences, this ratio decreased to 3.58, 2.16, 1.07 and 0.93 in the “very good”, “good”, “poor” and “worst” case scenarios, respectively. This suggests that in all but the worst-case scenario, donor investment would be exceeded by the non-donor expenditure it catalysed.

Conclusions

The unit cost per net delivered was high, reflecting considerable initial investment costs and relatively low volumes of LLINs sold during the short duration of the project. However, taking a longer time horizon and broader perspective on the consequences of this complex catalytic intervention suggests that considerable domestic resources for malaria control could be mobilized, exceeding the value of the initial donor investment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-022-04218-2.

Cost and cost effectiveness of reactive case detection (RACD), reactive focal mass drug administration (rfMDA) and reactive focal vector control (RAVC) to reduce malaria in the low endemic setting of Namibia: an analysis alongside a 2×2 factorial design cluster randomised controlled trial

OBJECTIVES

To estimate the cost and cost effectiveness of reactive case detection (RACD), reactive focal mass drug administration (rfMDA) and reactive focal vector control (RAVC) to reduce malaria in a low endemic setting.

SETTING

The study was part of a 2×2 factorial design cluster randomised controlled trial within the catchment area of 11 primary health facilities in Zambezi, Namibia.

PARTICIPANTS

Cost and outcome data were collected from the trial, which included 8948 community members that received interventions due to their residence within 500 m of malaria index cases.

OUTCOME MEASURES

The primary outcome was incremental cost effectiveness ratio (ICER) per in incident case averted. ICER per prevalent case and per disability-adjusted life years (DALY) averted were secondary outcomes, as were per unit interventions costs and personnel time. Outcomes were compared as: (1) rfMDA versus RACD, (2) RAVC versus no RAVC and (3) rfMDA+RAVC versus RACD only.

RESULTS

rfMDA cost 1.1× more than RACD, and RAVC cost 1.7× more than no RAVC. Relative to RACD only, the cost of rfMDA+RAVC was double ($3082 vs $1553 per event). The ICERs for rfMDA versus RACD, RAVC versus no RAVC and rfMDA+RAVC versus RACD only were $114, $1472 and $842, per incident case averted, respectively. Using prevalent infections and DALYs as outcomes, trends were similar. The median personnel time to implement rfMDA was 20% lower than for RACD (30 vs 38 min per person). The median personnel time for RAVC was 34 min per structure sprayed.

CONCLUSION

Implemented alone or in combination, rfMDA and RAVC were cost effective in reducing malaria incidence and prevalence despite higher implementation costs in the intervention compared with control arms. Compared with RACD, rfMDA was time saving. Cost and time requirements for the combined intervention could be decreased by implementing rfMDA and RAVC simultaneously by a single team.

TRIAL REGISTRATION NUMBER

NCT02610400; Post-results.

Factors associated with ownership and utilization of insecticide treated nets among children under five years in sub-Saharan Africa

Background

Insecticide-treated net (ITN) is a cost-effective means to control malaria and morbidity in under-five children. This study synthesizes the factors associated with using the ITN as a malaria prevention tool in sub-Saharan Africa.

Methods

There was an advanced search of four electronic databases, including PubMed Central, CINAHL, EMBASE, and Google Scholar, and identified articles between 2016 to April 2021. Following the title, abstract and full-text reading, 13 articles were deemed appropriate for this review. All the researchers developed, discussed, and accepted a matrix to extract relevant information from the studies. A convergent synthesis was adopted and allowed for integrating qualitative, quantitative, and mixed-method studies and transforming them into qualitative findings.

Results

Household and caregiver related factors that influenced utilization of the ITN were, Household heads having two or more sleeping places, a knowledge that ITN prevents malaria, the presence of hanging ITNs, high literacy, living female-headed households, birth spacing, unmarried mothers, and antenatal clinic attendance promoted utilization. Perceived malaria risk was a critical determinant of ITN ownership and utilization. Some factors that hindered the use of the ITN included hotness of the weather, absence of visible mosquitoes, cost, inadequate number, rooms designs, unaffordability, insufficient knowledge on causes of malaria, and poor attitude to use. Specific ITN factors that hindered use were color, chemicals use, odor, and shape.

Conclusion

It is important to use integrated multi-sectoral and culturally appropriate interventions to encourage households to prioritize and utilize the ITN in under-5 children.

Mark-release-recapture experiment in Burkina Faso demonstrates reduced fitness and dispersal of genetically-modified sterile malaria mosquitoes

Every year, malaria kills approximately 405,000 people in Sub-Saharan Africa, most of them children under the age of five years. In many countries, progress in malaria control has been threatened by the rapid spread of resistance to antimalarial drugs and insecticides. Novel genetic mosquito control approaches could play an important role in future integrated malaria control strategies. In July 2019, the Target Malaria consortium proceeded with the first release of hemizygous genetically-modified (GM) sterile and non-transgenic sibling males of the malaria mosquito Anopheles coluzzii in Burkina Faso. This study aimed to determine the potential fitness cost associated to the transgene and gather important information related to the dynamic of transgene-carrying mosquitoes, crucial for next development steps. Bayesian estimations confirmed that GM males had lower survival and were less mobile than their wild type (WT) siblings. The estimated male population size in Bana village, at the time of the release was 28,000 - 37,000. These results provide unique information about the fitness and behaviour of released GM males that will inform future releases of more effective strains of the A. gambiae complex.

Release of genetically-modified sterile mosquitoes is a potential method of malaria control but has yet to be tested in the field. Here, the authors perform a mark-release-recapture experiment and show that genetically-modified mosquitoes have reduced survival and dispersal compared to wild-types.

Time-Varying Effects of Meteorological Variables on Malaria Epidemiology in the Context of Interrupted Control Efforts in the Amazon Rainforest, 2000-2017

Successful malaria control interventions, mostly based on the training of health workers, distribution of insecticide-treated nets, and spraying, decrease malaria incidence; however, when these interventions are interrupted, a resurgence may occur. In the Peruvian Amazon, after discontinuing the control activities implemented by the PAMAFRO project (2006–2010)-a Global Fund-sponsored project for the strengthening of malaria control and surveillance in multiple countries in Latin America– malaria cases re-emerged dramatically. In parallel, meteorological factors determine the conditions suitable for the development, reproduction, and survival of mosquito vectors and parasites. This study hypothesized that interruption of malaria interventions may have modified the meteorological-malaria relationships over time (i.e., temporal changes in the dose-response between meteorological variables and malaria incidence). In this panel data analysis, we assessed the extent that relationships between meteorological variables and malaria changed temporally using data of monthly malaria incidence due to Plasmodium vivax or P. falciparum in Loreto, Peru (2000–2017). Generalized additive models were used to explore how the effects of meteorological variables changed in magnitude before, during, and after the PAMAFRO intervention. We found that once the PAMAFRO intervention had been interrupted, the estimated effects (dose-response) of meteorological variables on incidence rates decreased for both malaria parasite species. However, these fitted effect estimates did not reach their baseline levels (before the PAMAFRO period); variations of time-varying slopes between 0.45 and 2.07 times were observed after the PAMAFRO intervention. We also reported significant heterogeneity in the geographical distributions of malaria, parasite species, and meteorological variables. High malaria transmission occurred consistently in the northwestern provinces of Loreto Department. Since the end of the PAMAFRO period, a higher effect of precipitation and actual evapotranspiration was described on P. falciparum compared to P. vivax. The effect of temperature on malaria was greater over a shorter time (1-month lag or less), compared with precipitation and actual evapotranspiration (12-month lag). These findings demonstrate the importance of sustained malaria control efforts since interruption may enhance the links between meteorological factors and malaria. Our results also emphasize the importance of considering the time-varying effect of meteorological factors on malaria incidence to tailor control interventions, especially to better manage the current and future climate change crisis.

Forecasting Confirmed Malaria Cases in Northwestern Province of Zambia: A Time Series Analysis Using 2014–2020 Routine Data

Background. Malaria remains a significant public health problem, especially in resource-poor settings. We aimed to forecast the year 2021 monthly confirmed malaria cases in the northwestern province of Zambia. Methods. The total number of confirmed monthly malaria cases recorded at health facilities over the past 7-years period (January 2014 to December 2020) was taken from the District Health Information System version 2 (DHIS.2) database. Box–Jenkins autoregressive integrated moving average (ARIMA) was used to forecast monthly confirmed malaria cases for 2021. STATA software version 16 was used for analyzing the time series data. Results. Between 2014 and 2020, there were 3,795,541 confirmed malaria cases in the northwestern province with a monthly mean of 45,185 cases. ARIMA (2, 1, 2) (0, 1, 1)12 was the best fit and the most parsimonious model. The forecasted mean monthly confirmed malaria cases were 60,284 (95%CI 30,969–121,944), and the total forecasted confirmed malaria cases were 723,413 (95%CI 371,626–1,463,322) for the year 2021. Conclusion. The forecasted confirmed malaria cases suggest that there will be an increase in the number of confirmed malaria cases for the year 2021 in the northwestern province. Therefore, there is a need for concerted efforts to prevent and eliminate the disease if the goal to eliminate malaria in Zambia by 2030 is to be realized.

Estimating the programmatic cost of targeted mass drug administration for malaria in Myanmar

Background

Mass drug administration (MDA) has received growing interest to accelerate the elimination of multi-drug resistant malaria in the Greater Mekong Subregion. Targeted MDA, sometimes referred to as focal MDA, is the practice of delivering MDA to high incidence subpopulations only, rather than the entire population. The potential effectiveness of delivering targeted MDA was demonstrated in a recent intervention in Kayin State, Myanmar. Policymakers and funders need to know what resources are required if MDA, targeted or otherwise, is to be included in elimination packages beyond existing malaria interventions. This study aims to estimate the programmatic cost and the unit cost of targeted MDA in Kayin State, Myanmar.

Methods

We used financial data from a malaria elimination initiative, conducted in Kayin State, to estimate the programmatic costs of the targeted MDA component using a micro-costing approach. Three activities (community engagement, identification of villages for targeted MDA, and conducting mass treatment in target villages) were evaluated. We then estimated the programmatic costs of implementing targeted MDA to support P. falciparum malaria elimination in Kayin State. A costing tool was developed to aid future analyses.

Results

The cost of delivering targeted MDA within an integrated malaria elimination initiative in eastern Kayin State was approximately US$ 910,000. The cost per person reached, distributed among those in targeted and non-targeted villages, for the MDA component was US$ 2.5.

Conclusion

This cost analysis can assist policymakers in determining the resources required to clear malaria parasite reservoirs. The analysis demonstrated the value of using financial data from research activities to predict programmatic implementation costs of targeting MDA to different numbers of target villages.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10842-5.

A systematic review of factors influencing participation in two types of malaria prevention intervention in Southeast Asia

Background

Multi-pronged malaria elimination strategies are increasingly being considered for accelerating efforts against malaria transmission in Southeast Asia. Two malaria prevention interventions used in in the region are insecticide-treated bed-nets (ITNs) and mass drug administration (MDA). Universal access to ITNs is recommended and high population coverage (e.g. above 80%) is needed during MDA initiatives to maximize the impact of these interventions. However, variability in ITN use and individual MDA participation exists. This systematic review aims to provide a summary and overview of literature discussing factors influencing uptake of these two malaria control strategies in Southeast Asian countries.

Methods

A search of OVID Embase, OVID MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, OpenGrey, ProQuest, and Google Scholar was undertaken in February 2020. English-language publications with any study design using data from any of the ten member countries of the Association of Southeast Asian Nations were eligible for inclusion. In addition, reference lists of identified articles were manually searched. Websites for relevant international agencies were also searched to identify related grey literature.

Results

The review identified thirty publications that met the inclusion and exclusion criteria. Most discussed ITN use (n = 18) and were relevant to populations in Myanmar (n = 14). All MDA studies were published after 2016, whereas included ITN studies spanned from 1998 to 2020. Seven main themes emerged across the studies. Knowledge of malaria and attitudes towards ITNs were emphasized as key factors associated with ITN use. For MDA participation, key factors included the importance of positive attitudes towards the program, the influence of indirect costs and incentives, and the tendency for group decision-making.

Conclusions

As countries in Southeast Asia continue to work towards becoming malaria-free by 2030, the knowledge and attitudes of local population sub-groups should be assessed and incorporated into the planning and implementation of malaria prevention activities. The role of incentives and group decision making should also be considered particularly as they relate to MDA. There is need for ongoing involvement of health educators, the continuation of implementation research and the prioritization of community engagement efforts alongside malaria interventions in the region.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12936-021-03733-y.

Vector-Focused Approaches to Curb Malaria Transmission in the Brazilian Amazon: An Overview of Current and Future Challenges and Strategies

In Brazil, malaria transmission is mostly confined to the Amazon, where substantial progress has been made towards disease control in the past decade. Vector control has been historically considered a fundamental part of the main malaria control programs implemented in Brazil. However, the conventional vector-control tools have been insufficient to control or eliminate local vector populations due to the complexity of the Amazonian rainforest environment and ecological features of malaria vector species in the Amazon, especially Anopheles darlingi. Malaria elimination in Brazil and worldwide eradication will require a combination of conventional and new approaches that takes into account the regional specificities of vector populations and malaria transmission dynamics. Here we present an overview on both conventional and novel promising vector-focused tools to curb malaria transmission in the Brazilian Amazon. If well designed and employed, vector-based approaches may improve the implementation of malaria-control programs, particularly in remote or difficult-to-access areas and in regions where existing interventions have been unable to eliminate disease transmission. However, much effort still has to be put into research expanding the knowledge of neotropical malaria vectors to set the steppingstones for the optimization of conventional and development of innovative vector-control tools.

Potential functions of atypical memory B cells in Plasmodium-exposed individuals

Naturally acquired iummunity against clinical malaria is slow to develop, taking years of repeated exposure to parasites to acquire sufficiently broad and potent antibody responses. Increasing evidence suggests that Plasmodium infection and the resulting immune stimulation contribute to changes in the B cell compartment. In particular, accumulation of atypical memory B cells (atMBCs) is common in Plasmodium-exposed individuals. Similarities to B cell subsets present in other acute and chronic disease settings have provided insight into the development and potential function of these cells; however, their contribution to protection against malaria is still poorly understood. Here, we discuss recent findings that have increased our understanding of atMBCs and outline outstanding questions related to their function and development in the protective immune response to malaria.

Burden of communicable diseases and cost of illness: Asia pacific region

BACKGROUND

Communicable diseases such as AIDS/HIV, dengue fever, and malaria have a great burden and subsequent economic loss in the Asian region. The purpose of this article is to review the widespread burden of communicable diseases and related health-care burden for the patient in Asia and the Pacific.

AREAS COVERED

In Central Asia, the number of new AIDS cases increased by 29%. It is more endemic in the poor population with variations in the cost of illness. Dengue is prevalent in more than 100 countries, including the Asia-Pacific region. In Southeast Asia, the annual economic burden of dengue fever was between $ 610 and $ 1,384 million, with a per capita cost of $ 1.06 to $ 2.41. Globally, 2.9 billion people are at risk of developing malaria, 90% of whom are residents of the Asia and Pacific region. The annual per capita cost of malaria control ranged from $ 0.11 to $ 39.06 and for elimination from $ 0.18 to $ 27.

EXPERT OPINION

The cost of AIDS, dengue, and malaria varies from country to country due to different health-care systems. The literature review has shown that the cost of dengue disease and malaria is poorly documented.

An economic analysis of malaria elimination program in Nepal

BACKGROUND

Governments have committed to eliminate malaria. But a decline in government investment in malaria interventions, particularly in developing countries such as Nepal, reveals a limited emphasis on malaria elimination that may be due to lack of strong evidence on benefits of the investment. This paper empirically analyses curative and preventive costs and benefits of Nepal's malaria elimination program from the perspectives of both service providers in the public sector and people who are at risk.

METHODS

Cost benefit analysis of both curative and preventive interventions for malaria elimination was conducted using case and non-case household survey data. Secondary data were obtained from government sources. Ingredient approach and step-down methods were used to estimate costs of malaria elimination interventions, and willingness to pay (WTP) method and case averted approach to estimate benefits.

RESULTS

Curative intervention of malaria elimination program is economically viable in Nepal with a net present value (NPV) of USD 23 million, benefit cost ratio (BCR) of 1.58 and internal rate of return of 63%. Malaria preventive intervention is highly beneficial with NPV of USD 435 million and BCR of 2.13. An annual investment of USD 36.59 million is required to continue the current pattern of malaria reduction that can generate societal benefits of USD 92.81 million. From this investment, the government can save USD 132 million by the end of 2025. The maximum WTP of case households for the intervention is USD 57 per household which is 63% higher than that of non-case households.

CONCLUSION

Malaria elimination program in Nepal is economically viable and investment worthy. As the preventive intervention generates much higher net benefits than the curative intervention, the government should emphasize on preventive intervention while continuing the curative interventions.

Diversity and Multiplicity of P. falciparum infections among asymptomatic school children in Mbita, Western Kenya

Multiplicity of infection (MOI) and genetic diversity of P. falciparum infections are important surrogate indicators for assessing malaria transmission intensity in different regions of endemicity. Determination of MOI and diversity of P. falciparum among asymptomatic carriers will enhance our understanding of parasite biology and transmission to mosquito vectors. This study examined the MOI and genetic diversity of P. falciparum parasite populations circulating in Mbita, a region characterized as one of the malaria hotspots in Kenya. The genetic diversity and multiplicity of P. falciparum infections in 95 asymptomatic school children (age 5–15 yrs.) residing in Mbita, western Kenya were assessed using 10 polymorphic microsatellite markers. An average of 79.69% (Range: 54.84–95.74%) of the isolates analysed in this study were polyclonal infections as detected in at least one locus. A high mean MOI of 3.39 (Range: 2.24–4.72) and expected heterozygosity (He) of 0.81 (Range: 0.57–0.95) was reported in the study population. The analysed samples were extensively polyclonal infections leading to circulation of highly genetically diverse parasite populations in the study area. These findings correlated with the expectations of high malaria transmission intensity despite scaling up malaria interventions in the area thereby indicating the need for a robust malaria interventions particularly against asymptomatic carriers in order to attain elimination in the region.

The Investment Case for Malaria Elimination in Thailand: A Cost-Benefit Analysis

After a dramatic decline in the annual malaria incidence in Thailand since 2000, the Thai government developed a National Malaria Elimination Strategy (NMES) to end local malaria transmission by 2024. This study examines the expected costs and benefits of funding the NMES (elimination scenario) versus not funding malaria elimination programming (resurgence scenario) from 2017 to 2036. Two case projection approaches were used to measure the number of malaria cases over the study period, combined with a set of Thailand-specific economic assumptions, to evaluate the cost of a malaria case and to quantify the cost-benefit ratio of elimination. Model A projects cases based on national historical case data using a log-normal regression and change-point analysis model. Model B projects cases based on periodic Yala Province-level outbreak cycles and incorporating NMES political and programmatic goals. In the base case, both models predict that elimination would prevent 1.86-3.11 million malaria cases from 2017 to 2036, with full NMES implementation proving to be cost-saving in all models, perspectives, and scenarios, except for the health system-only perspective in the Model A base case and all perspectives in the Model A worst case. From the societal perspective, every 1 US dollars (US$) spent on the NMES would-depending on case projections used-potentially result in a considerable return on investment, ranging from US$ 2 to US$ 15. Although the two case projection approaches resulted in different cost-benefit ratios, both models showed cost savings and suggest that ending local malaria transmission in Thailand would yield a positive return on investment.

Cost-effectiveness analysis of malaria rapid diagnostic tests: a systematic review

Background

Rapid diagnostic tests (RDT) can effectively manage malaria cases and reduce excess costs brought by misdiagnosis. However, few studies have evaluated the economic value of this technology. The purpose of this study is to systematically review the economic value of RDT in malaria diagnosis.

Main text

A detailed search strategy was developed to identify published economic evaluations that provide evidence regarding the cost-effectiveness of malaria RDT. Electronic databases including MEDLINE, EMBASE, Biosis Previews, Web of Science and Cochrane Library were searched from Jan 2007 to July 2018. Two researchers screened studies independently based on pre-specified inclusion and exclusion criteria. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was applied to evaluate the quality of the studies. Then cost and effectiveness data were extracted and summarized in a narrative way.

Fifteen economic evaluations of RDT compared to other diagnostic methods were identified. The overall quality of studies varied greatly but most of them were scored to be of high or moderate quality. Ten of the fifteen studies reported that RDT was likely to be a cost-effective approach compared to its comparisons, but the results could be influenced by the alternatives, study perspectives, malaria prevalence, and the types of RDT.

Conclusions

Based on available evidence, RDT had the potential to be more cost-effective than either microscopy or presumptive diagnosis. Further research is also required to draw a more robust conclusion.

Characterizing the Spatial Determinants and Prevention of Malaria in Kenya

The United Nations' Sustainable Development Goal 3 is to ensure health and well-being for all at all ages with a specific target to end malaria by 2030. Aligned with this goal, the primary objective of this study is to determine the effectiveness of utilizing local spatial variations to uncover the statistical relationships between malaria incidence rate and environmental and behavioral factors across the counties of Kenya. Two data sources are used-Kenya Demographic and Health Surveys of 2000, 2005, 2010, and 2015, and the national Malaria Indicator Survey of 2015. The spatial analysis shows clustering of counties with high malaria incidence rate, or hot spots, in the Lake Victoria region and the east coastal area around Mombasa; there are significant clusters of counties with low incidence rate, or cold spot areas in Nairobi. We apply an analysis technique, geographically weighted regression, that helps to better model how environmental and social determinants are related to malaria incidence rate while accounting for the confounding effects of spatial non-stationarity. Some general patterns persist over the four years of observation. We establish that variables including rainfall, proximity to water, vegetation, and population density, show differential impacts on the incidence of malaria in Kenya. The El-Nino-southern oscillation (ENSO) event in 2015 was significant in driving up malaria in the southern region of Lake Victoria compared with prior time-periods. The applied spatial multivariate clustering analysis indicates the significance of social and behavioral survey responses. This study can help build a better spatially explicit predictive model for malaria in Kenya capturing the role and spatial distribution of environmental, social, behavioral, and other characteristics of the households.

"Remarkable solutions to impossible problems": lessons for malaria from the eradication of smallpox

Background

Malaria elimination and eventual eradication will require internationally coordinated approaches; sustained engagement from politicians, communities, and funders; efficient organizational structures; innovation and new tools; and well-managed programmes. As governments and the global malaria community seek to achieve these goals, their efforts should be informed by the substantial past experiences of other disease elimination and eradication programmes, including that of the only successful eradication programme of a human pathogen to date: smallpox.

Methods

A review of smallpox literature was conducted to evaluate how the smallpox programme addressed seven challenges that will likely confront malaria eradication efforts, including fostering international support for the eradication undertaking, coordinating programmes and facilitating research across the world’s endemic countries, securing sufficient funding, building domestic support for malaria programmes nationally, ensuring strong community support, identifying the most effective programmatic strategies, and managing national elimination programmes efficiently.

Results

Review of 118 publications describing how smallpox programmes overcame these challenges suggests eradication may succeed as a collection of individual country programmes each deriving local solutions to local problems, yet with an important role for the World Health Organization and other international entities to facilitate and coordinate these efforts and encourage new innovations. Publications describing the smallpox experience suggest the importance of avoiding burdensome bureaucracy while employing flexible, problem-solving staff with both technical and operational backgrounds to overcome numerous unforeseen challenges. Smallpox’s hybrid strategy of leveraging basic health services while maintaining certain separate functions to ensure visibility, clear targets, and strong management, aligns with current malaria approaches. Smallpox eradication succeeded by employing data-driven strategies that targeted resources to the places where they were most needed rather than attempting to achieve mass coverage everywhere, a potentially useful lesson for malaria programmes seeking universal coverage with available tools. Finally, lessons from smallpox programmes suggest strong engagement with the private sector and affected communities can help increase the sustainability and reach of today’s malaria programmes.

Conclusions

It remains unclear whether malaria eradication is feasible, but neither was it clear whether smallpox eradication was feasible until it was achieved. To increase chances of success, malaria programmes should seek to strengthen programme management, measurement, and operations, while building flexible means of sharing experiences, tools, and financing internationally.

The first introduced malaria case reported from Sri Lanka after elimination: implications for preventing the re-introduction of malaria in recently eliminated countries

BACKGROUND

There has been no local transmission of malaria in Sri Lanka for 6 years following elimination of the disease in 2012. Malaria vectors are prevalent in parts of the country, and imported malaria cases continue to be reported. The country is therefore at risk of malaria being re-established. The first case of introduced vivax malaria in the country is reported here, and the surveillance and response system that contained the further spread of this infection is described.

METHODS

Diagnosis of malaria was based on microscopy and rapid diagnostic tests. Entomological surveillance for anophelines used standard techniques for larval and adult surveys. Genotyping of parasite isolates was done using a multi-locus direct sequencing approach, combined with cloning and restriction fragment length polymorphism analyses. Treatment of vivax malaria infections was according to the national malaria treatment guidelines.

RESULTS

An imported vivax malaria case was detected in a foreign migrant followed by a Plasmodium vivax infection in a Sri Lankan national who visited the residence of the former. The link between the two cases was established by tracing the occurrence of events and by demonstrating genetic identity between the parasite isolates. Effective surveillance was conducted, and a prompt response was mounted by the Anti Malaria Campaign. No further transmission occurred as a result.

CONCLUSIONS

Evidence points to the case of malaria in the Sri Lankan national being an introduced malaria case transmitted locally from an infection in the foreign migrant labourer, which was the index case. Case detection, treatment and investigation, followed by prompt action prevented further transmission of these infections. Entomological surveillance and vector control at the site of transmission were critically important to prevent further transmission. The case is a reminder that the risk of re-establishment of the disease in the country is high, and that the surveillance and response system needs to be sustained in this form at least until the Southeast Asian region is free of malaria. Several countries that are on track to eliminate malaria in the coming years are in a similar situation of receptivity and vulnerability. Regional elimination of malaria must therefore be considered a priority if the gains of global malaria elimination are to be sustained.

Seasonal malaria vector and transmission dynamics in western Burkina Faso

BACKGROUND

In the context of widespread mosquito resistance to currently available pesticides, novel, precise genetic vector control methods aimed at population suppression or trait replacement are a potentially powerful approach that could complement existing malaria elimination interventions. Such methods require knowledge of vector population composition, dynamics, behaviour and role in transmission. Here were characterized these parameters in three representative villages, Bana, Pala and Souroukoudingan, of the Sudano-Sahelian belt of Burkina Faso, a region where bed net campaigns have recently intensified.

METHODS

From July 2012 to November 2015, adult mosquitoes were collected monthly using pyrethroid spray catches (PSC) and human landing catches (HLC) in each village. Larval habitat prospections assessed breeding sites abundance at each site. Mosquitoes collected by PSC were identified morphologically, and then by molecular technique to species where required, to reveal the seasonal dynamics of local vectors. Monthly entomological inoculation rates (EIR) that reflect malaria transmission dynamics were estimated by combining the HLC data with mosquito sporozoite infection rates (SIR) identified through ELISA-CSP. Finally, population and EIR fluctuations were fit to locally-collected rainfall data to highlight the strong seasonal determinants of mosquito abundance and malaria transmission in this region.

RESULTS

The principal malaria vectors found were in the Anopheles gambiae complex. Mosquito abundance peaked during the rainy season, but there was variation in vector species composition between villages. Mean survey HLC and SIR were similar across villages and ranged from 18 to 48 mosquitoes/person/night and from 3.1 to 6.6% prevalence. The resulting monthly EIRs were extremely high during the rainy season (0.91-2.35 infectious bites/person/day) but decreased substantially in the dry season (0.03-0.22). Vector and malaria transmission dynamics generally tracked seasonal rainfall variations, and the highest mosquito abundances and EIRs occurred in the rainy season. However, despite low residual mosquito populations, mosquitoes infected with malaria parasites remained present in the dry season.

CONCLUSION

These results highlight the important vector control challenge facing countries with high EIR despite the recent campaigns of bed net distribution. As demonstrated in these villages, malaria transmission is sustained for large parts of the year by a very high vector abundance and high sporozoite prevalence, resulting in seasonal patterns of hyper and hypo-endemicity. There is, therefore, an urgent need for additional vector control tools that can target endo and exophillic mosquito populations.

One-sample aggregate data meta-analysis of medians

An aggregate data meta-analysis is a statistical method that pools the summary statistics of several selected studies to estimate the outcome of interest. When considering a continuous outcome, typically each study must report the same measure of the outcome variable and its spread (eg, the sample mean and its standard error). However, some studies may instead report the median along with various measures of spread. Recently, the task of incorporating medians in meta-analysis has been achieved by estimating the sample mean and its standard error from each study that reports a median in order to meta-analyze the means. In this paper, we propose two alternative approaches to meta-analyze data that instead rely on medians. We systematically compare these approaches via simulation study to each other and to methods that transform the study-specific medians and spread into sample means and their standard errors. We demonstrate that the proposed median-based approaches perform better than the transformation-based approaches, especially when applied to skewed data and data with high inter-study variance. Finally, we illustrate these approaches in a meta-analysis of patient delay in tuberculosis diagnosis.

Are malaria elimination efforts on right track? An analysis of gains achieved and challenges ahead

Background

Malaria causes significant morbidity and mortality each year. In the past few years, the global malaria cases have been declining and many endemic countries are heading towards malaria elimination. Nevertheless, reducing the number of cases seems to be easy than sustained elimination. Therefore to achieve the objective of complete elimination and maintaining the elimination status, it is necessary to assess the gains made during the recent years.

Main text

With inclining global support and World Health Organisation (WHO) efforts, the control programmes have been implemented effectively in many endemic countries. Given the aroused interest and investments into malaria elimination programmes at global level, the ambitious goal of elimination appears feasible. Sustainable interventions have played a pivotal role in malaria contraction, however drug and insecticide resistance, social, demographic, cultural and behavioural beliefs and practices, and unreformed health infrastructure could drift back the progress attained so far. Ignoring such impeding factors coupled with certain region specific factors may jeopardise our ability to abide righteous track to achieve global elimination of malaria parasite. Although support beyond the territories is important, but well managed integrated vector management approach at regional and country level using scrupulously selected area specific interventions targeting both vector and parasite along with the community involvement is necessary. A brief incline in malaria during 2016 has raised fresh perturbation on whether elimination could be achieved on time or not.

Conclusions

The intervention tools available currently can most likely reduce transmission but clearing of malaria epicentres from where the disease can flare up any time, is not possible without involving local population. Nevertheless maintaining zero malaria transmission and checks on malaria import in declared malaria free countries, and further speeding up of interventions to stop transmission in elimination countries is most desirable. Strong collaboration backed by adequate political and financial support among the countries with a common objective to eliminate malaria must be on top priority. The present review attempts to assess the progress gained in malaria elimination during the past few years and highlights some issues that could be important in successful malaria elimination.

Electronic supplementary material

The online version of this article (10.1186/s40249-019-0524-x) contains supplementary material, which is available to authorized users.

Cost-effectiveness of a combined intervention of long lasting insecticidal nets and indoor residual spraying compared with each intervention alone for malaria prevention in Ethiopia

Background

The effectiveness of long lasting insecticidal nets (LLINs) and indoor residual spraying (IRS), for malaria prevention, have been established in several studies. However, the available evidence about the additional resources required for a combined implementation (LLIN + IRS) with respect to the added protection afforded is limited. Therefore, the aim of this study was to compare the cost-effectiveness of combined implementation of LLINs and IRS, compared with LLINs alone, IRS alone, and routine practice in Ethiopia.

Methods

The study was performed alongside a cluster randomized controlled trial of malaria prevention conducted in Adami Tullu district, in Ethiopia, from 2014 to 2016. In addition, literature-based cost-effectiveness analysis—using effectiveness information from a systematic review of published articles was conducted. Costing of the interventions were done from the providers’ perspective. The health-effect was measured using disability adjusted life years (DALYs) averted, and combined with cost information using a Markov life-cycle model. In the base-case analysis, health-effects were based on the current trial, and in addition, a scenario analysis was performed based on a literature survey.

Results

The current trial-based analysis showed that routine practice is not less effective and therefore dominates both the combined intervention and singleton intervention due to lower costs. The literature-based analysis had shown that combined intervention had an incremental cost-effectiveness ratio of USD 1403 per DALY averted, and USD 207 per DALY averted was estimated for LLIN alone. In order for the ICER for the combined intervention to be within a range of 1 GDP per capita per DALY averted, the annual malaria incidence in the area should be at least 13%, and the protective-effectiveness of combined implementation should be at least 53%.

Conclusions

Based on the current trial-based analysis, LLINs and IRS are not cost-effective compared to routine practice. However, based on the literature-based analysis, LLIN alone is likely to be cost-effective compared to 3 times GDP per capita per DALY averted. The annual malaria probability and protective-effectiveness of combined intervention are key determinants of the cost-effectiveness of the interventions.

Trial registration PACTR201411000882128 (Registered 8 September 2014). http://www.pactr.org/ATMWeb/appmanager/atm/atmregistry?dar=true&tNo=PACTR201411000882128

Role of phospholipid synthesis in the development and differentiation of malaria parasites in the blood

The life cycle of malaria parasites in both their mammalian host and mosquito vector consists of multiple developmental stages that ensure proper replication and progeny survival. The transition between these stages is fueled by nutrients scavenged from the host and fed into specialized metabolic pathways of the parasite. One such pathway is used by Plasmodium falciparum, which causes the most severe form of human malaria, to synthesize its major phospholipids, phosphatidylcholine, phosphatidylethanolamine, and phosphatidylserine. Much is known about the enzymes involved in the synthesis of these phospholipids, and recent advances in genetic engineering, single-cell RNA-Seq analyses, and drug screening have provided new perspectives on the importance of some of these enzymes in parasite development and sexual differentiation and have identified targets for the development of new antimalarial drugs. This Minireview focuses on two phospholipid biosynthesis enzymes of P. falciparum that catalyze phosphoethanolamine transmethylation (PfPMT) and phosphatidylserine decarboxylation (PfPSD) during the blood stages of the parasite. We also discuss our current understanding of the biochemical, structural, and biological functions of these enzymes and highlight efforts to use them as antimalarial drug targets.

Costs and cost-effectiveness of malaria reactive case detection using loop-mediated isothermal amplification compared to microscopy in the low transmission setting of Aceh Province, Indonesia

Background

Reactive case detection (RACD) is an active case finding strategy where households and neighbours of a passively identified case (index case) are screened to identify and treat additional malaria infections with the goal of gathering surveillance information and potentially reducing further transmission. Although it is widely considered a key strategy in low burden settings, little is known about the costs and the cost-effectiveness of different diagnostic methods used for RACD. The aims of this study were to measure the cost of conducting RACD and compare the cost-effectiveness of microscopy to the more sensitive diagnostic method loop-mediated isothermal amplification (LAMP).

Methods

The study was conducted in RACD surveillance sites in five sub-districts in Aceh Besar, Indonesia. The cost inputs and yield of implementing RACD with microscopy and/or LAMP were collected prospectively over a 20 months study period between May 2014 and December 2015. Costs and cost-effectiveness (USD) of the different strategies were examined. The main cost measures were cost per RACD event, per person screened, per population at risk (PAR); defined as total population in each sub-district, and per infection found. The main cost-effectiveness measure was incremental cost-effectiveness ratio (ICER), expressed as cost per malaria infection detected by LAMP versus microscopy. The effects of varying test positivity rate or diagnostic yield on cost per infection identified and ICER were also assessed.

Results

Among 1495 household members and neighbours screened in 36 RACD events, two infections were detected by microscopy and confirmed by LAMP, and four infections were missed by microscopy but detected by LAMP. The average total cost of conducting RACD using microscopy and LAMP was $1178 per event with LAMP-specific consumables and personnel being the main cost drivers. The average cost of screening one individual during RACD was $11, with an additional cost of diagnostics at $0.62 and $16 per person for microscopy and LAMP, respectively. As a public health intervention, RACD using both diagnostics cost an average of $0.42 per PAR per year. Comparing RACD using microscopy only versus RACD using LAMP only, the cost per infection found was $8930 and $6915, respectively. To add LAMP as an additional intervention accompanying RACD would cost $9 per individual screened annually in this setting. The ICER was estimated to be $5907 per additional malaria infection detected by LAMP versus microscopy. Cost per infection identified and ICER declined with increasing test positivity rate and increasing diagnostic yield.

Conclusions

This study provides the first estimates on the cost and cost-effectiveness of RACD from a low transmission setting. Costs per individual screened were high, though costs per PAR were low. Compared to microscopy, the use of LAMP in RACD was more costly but more cost-effective for the detection of infections, with diminishing returns observed when findings were extrapolated to scenarios with higher prevalence of infection using more sensitive diagnostics. As malaria programmes consider active case detection and the integration of more sensitive diagnostics, these findings may inform strategic and budgetary planning.

Electronic supplementary material

The online version of this article (10.1186/s12936-018-2361-y) contains supplementary material, which is available to authorized users.

Scaling up malaria intervention "packages" in Senegal: using cost effectiveness data for improving allocative efficiency and programmatic decision-making

Background

Senegal’s National Malaria Control Programme (NMCP) implements control interventions in the form of targeted packages: (1) scale-up for impact (SUFI), which includes bed nets, intermittent preventive treatment in pregnancy, rapid diagnostic tests, and artemisinin combination therapy; (2) SUFI + reactive case investigation (focal test and treat); (3) SUFI + indoor residual spraying (IRS); (4) SUFI + seasonal malaria chemoprophylaxis (SMC); and, (5) SUFI + SMC + IRS. This study estimates the cost effectiveness of each of these packages to provide the NMCP with data for improving allocative efficiency and programmatic decision-making.

Methods

This study is a retrospective analysis for the period 2013–2014 covering all 76 Senegal districts. The yearly implementation cost for each intervention was estimated and the information was aggregated into a package cost for all covered districts. The change in the burden of malaria associated with each package was estimated using the number of disability adjusted life-years (DALYs) averted. The cost effectiveness (cost per DALY averted) was then calculated for each package.

Results

The cost per DALY averted ranged from $76 to $1591 across packages. Using World Health Organization standards, 4 of the 5 packages were “very cost effective” (less than Senegal’s GDP per capita). Relative to the 2 other packages implemented in malaria control districts, the SUFI + SMC package was the most cost-effective package at $76 per DALY averted. SMC seems to make IRS more cost effective: $582 per DALY averted for SUFI + IRS compared with $272 for the SUFI + IRS + SMC package. The SUFI + focal test and treat, implemented in malaria elimination districts, had a cost per DALY averted of $1591 and was only “cost-effective” (less than three times Senegal’s per capita GDP).

Conclusion

Senegal’s choice of deploying malaria interventions by packages seems to be effectively targeting high burden areas with a wide range of interventions. However, not all districts showed the same level of performance, indicating that efficiency gains are still possible.

Cost-effectiveness of adding indoor residual spraying to case management in Afghan refugee settlements in Northwest Pakistan during a prolonged malaria epidemic

Introduction

Financing of malaria control for displaced populations is limited in scope and duration, making cost-effectiveness analyses relevant but difficult. This study analyses cost-effectiveness of adding prevention through targeted indoor residual spraying (IRS) to case management in Afghan refugee settlements in Pakistan during a prolonged malaria epidemic.

Methods/Findings

An intervention study design was selected, taking a societal perspective. Provider and household costs of vector control and case management were collected from provider records and community survey. Health outcomes (e.g. cases and DALYs averted) were derived and incremental cost-effectiveness ratios (ICERs) for cases prevented and DALYs averted calculated. Population, treatment cost, women’s time, days of productivity lost, case fatality rate, cases prevented, and DALY assumptions were tested in sensitivity analysis. Malaria incidence peaked at 44/1,000 population in year 2, declining to 14/1,000 in year 5. In total, 370,000 malaria cases, 80% vivax, were diagnosed and treated and an estimated 67,988 vivax cases and 18,578 falciparum and mixed cases prevented. Mean annual programme cost per capita was US$0.56. The additional cost of including IRS over five years per case prevented was US$39; US$50 for vivax (US$43 in years 1–3, US$80 in years 4–5) and US$182 for falciparum (US$139 in years 1–3 and US$680 in years 4–5). Per DALY averted this was US$266 (US$220 in years 1–3 and US$486 in years 4–5) and thus ‘highly cost-effective’ or cost-effective using WHO and comparison thresholds.

Conclusions

Adding IRS was cost-effective in this moderate endemicity, low mortality setting. It was more cost-effective when transmission was highest, becoming less so as transmission reduced. Because vivax was three times more common than falciparum and the case fatality rate was low, cost-effectiveness estimations for cases prevented appear reliable and more definitive for vivax malaria.

We conducted a cost-effectiveness analysis of adding malaria prevention to routine malaria diagnosis and treatment in Afghan refugee settlements in Pakistan during a five-year malaria epidemic. We found that malaria incidence peaked at 44 per 1,000 in year 2 and declined to 14 per 1,000 in year 5, with an average annual programme cost per capita of US$0.56 in 2015 currency. Cost per case prevented averaged US$88 (US$111 for vivax, US$442 for falciparum), per death prevented averaged US$316,734, and per DALY averted averaged US$601. The additional cost of including IRS over five years per case prevented was US$39 (US$50 for vivax and US$182 for falciparum malaria case prevented) and per DALY averted was US$266. While our cost-effectiveness results were relatively high, when compared with internationally recognised cost-effectiveness thresholds both prevention and case management were highly cost-effective, indicating the relevance of an integrated approach for epidemic malaria control and global malaria elimination.