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Dial NJ, Medley GF, Croft SL, Mahapatra T, Priyamvada K, Sinha B, Palmer L, Terris-Prestholt F. Costs and outcomes of active and passive case detection for visceral leishmaniasis (Kala-Azar) to inform elimination strategies in Bihar, India. PLoS Negl Trop Dis 2021; 15:e0009129. [PMID: 33534836 PMCID: PMC7886142 DOI: 10.1371/journal.pntd.0009129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 02/16/2021] [Accepted: 01/13/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Effective case identification strategies are fundamental to capturing the remaining visceral leishmaniasis (VL) cases in India. To inform government strategies to reach and sustain elimination benchmarks, this study presents costs of active- and passive- case detection (ACD and PCD) strategies used in India's most VL-endemic state, Bihar, with a focus on programme outcomes stratified by district-level incidence. METHODS Expenditure analysis was complemented by onsite micro-costing to compare the cost of PCD in hospitals alongside index case-based ACD and a combination of blanket (house-to-house) and camp ACD from January to December 2018. From the provider's perspective, a cost analysis evaluated the overall programme cost of each activity, the cost per case detected, and the cost of scaling up ACD. RESULTS During 2018, index case-based ACD, blanket and camp ACD, and PCD reported 1,497, 131, and 1,983 VL-positive cases at a unit cost of $522.81, $4,186.81, and $246.79, respectively. In high endemic districts, more VL cases were identified through PCD while in meso- and low-endemic districts more cases were identified through ACD. The cost of scaling up ACD to identify 3,000 additional cases ranged from $1.6-4 million, depending on the extent to which blanket and camp ACD was relied upon. CONCLUSION Cost per VL test conducted (rather than VL-positive case identified) may be a better metric estimating unit costs to scale up ACD in Bihar. As more VL cases were identified in meso-and low-endemic districts through ACD than PCD, health authorities in India should consider bolstering ACD in these areas. Blanket and camp ACD identified fewer cases at a higher unit cost than index case-based ACD. However, the value of detecting additional VL cases early outweighs long-term costs for reaching and sustaining VL elimination benchmarks in India.
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Affiliation(s)
- Natalie J. Dial
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Graham F. Medley
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Simon L. Croft
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Tanmay Mahapatra
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | - Bikas Sinha
- CARE India Solutions for Sustainable Development, Patna, Bihar, India
| | | | - Fern Terris-Prestholt
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Freire ML, de Souza A, Cota G, Rabello A, Machado de Assis T. Cost-effectiveness of serological tests for human visceral leishmaniasis in the Brazilian scenario. PLoS Negl Trop Dis 2020; 14:e0008741. [PMID: 33031382 PMCID: PMC7544087 DOI: 10.1371/journal.pntd.0008741] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 08/24/2020] [Indexed: 11/18/2022] Open
Abstract
Human visceral leishmaniasis (VL) is a severe and potentially fatal parasitic disease if not correctly diagnosed and treated. Brazil is one of the three countries most endemic for VL and, like most countries affected by this disease, has a large budget constraint for the incorporation of new health technologies. Although different diagnostic tests for VL are currently available in the country, economic studies evaluating diagnostic kits are scarce. The objective of this study was to conduct a cost-effectiveness analysis of the nine available diagnostic tests for human VL in HIV-infected and uninfected patients in Brazil. The perspective of analysis was the Brazilian public health system, and the outcome of interest was "cases diagnosed correctly". The costs of the tests were estimated using the microcosting technique, and comparisons were performed with decision trees. Sensitivity analyses were explored applying variations in cost and effectiveness values. For VL diagnosis among HIV-uninfected patients, using blood samples for the rapid tests (RDTs), the noncommercial direct agglutination test (DAT-LPC) and IT-LEISH were cost-effective tests compared with the baseline OnSite test, but they presented different incremental cost-effectiveness ratios (ICER) of US$7.04 and US$ 205.40, respectively. Among HIV-infected patients, DAT-LPC was the most cost-effective diagnostic test. Comparisons among the tests with the same methodology, based on the low ICER values, revealed that IT-LEISH was the most cost-effective test among the RDTs and the Ridascreen Leishmania Ab among the ELISA tests. These results confirm that cost-effectiveness analyses can provide useful information to support the incorporation of new health technologies within a known scenario and willingness to pay threshold. It was observed that tests based on the same methodologies presented different cost-effectiveness ratios for the same group of patients and that different tests should be recommended for different patient groups. DAT-LPC was an important cost-effective strategy for all patients, requiring minimum laboratorial infrastructure, and IT-LEISH was the cost-effective test for VL screening in HIV-uninfected patients. IT-LEISH and DAT-LPC have complementary profiles and should both be provided by the Brazilian health system.
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Affiliation(s)
- Mariana Lourenço Freire
- Pesquisa Clínica e Políticas Públicas em Doenças Infecciosas e Parasitárias, Instituto René Rachou, Fundação Oswaldo Cruz, Barro Preto, Belo Horizonte, Minas Gerais, Brasil
| | - Aline de Souza
- Pesquisa Clínica e Políticas Públicas em Doenças Infecciosas e Parasitárias, Instituto René Rachou, Fundação Oswaldo Cruz, Barro Preto, Belo Horizonte, Minas Gerais, Brasil
| | - Gláucia Cota
- Pesquisa Clínica e Políticas Públicas em Doenças Infecciosas e Parasitárias, Instituto René Rachou, Fundação Oswaldo Cruz, Barro Preto, Belo Horizonte, Minas Gerais, Brasil
| | - Ana Rabello
- Pesquisa Clínica e Políticas Públicas em Doenças Infecciosas e Parasitárias, Instituto René Rachou, Fundação Oswaldo Cruz, Barro Preto, Belo Horizonte, Minas Gerais, Brasil
| | - Tália Machado de Assis
- Pesquisa Clínica e Políticas Públicas em Doenças Infecciosas e Parasitárias, Instituto René Rachou, Fundação Oswaldo Cruz, Barro Preto, Belo Horizonte, Minas Gerais, Brasil
- Centro Federal de Educação Tecnológica de Minas Gerais, Campus Contagem, Alameda das Perdizes, Cabral, Contagem, Minas Gerais, Brasil
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Sevá ADP, Ferreira F, Amaku M. How much does it cost to prevent and control visceral leishmaniasis in Brazil? Comparing different measures in dogs. PLoS One 2020; 15:e0236127. [PMID: 32692783 PMCID: PMC7373293 DOI: 10.1371/journal.pone.0236127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/29/2020] [Indexed: 11/19/2022] Open
Abstract
Visceral leishmaniasis (VL) is an important zoonosis in Brazil. Dogs are considered the main domestic reservoirs of the disease in the country; hence, control measures are focused on these reservoirs. Despite efforts to prevent and control VL, important reductions in disease prevalence and incidence have not been identified, stimulating the development and application of new strategies. The choice and implementation of new control strategies can benefit from the application of mathematical models that allow the simulation of different strategies in different scenarios. Selecting the best strategy to be implemented is also supported by cost-effectiveness studies. Here we used the results of a mathematical model in which scenarios, including isolated use of the vaccine and insecticide-impregnated collar (IIC), both at different coverage rates, were simulated to conduct a cost-effectiveness study. The costs were calculated for each scenario considering a simulation period of four years. Collar application in both infected and non-infected animals was the most cost-effective strategy. For example, to reduce the prevalence in humans and dogs by approximately 70%, the costs ranged from $250,000 and $550,000 for the IICs and vaccination, respectively. Even in the scenario with 40% loss/replacement of IICs, this measure was more advantageous in terms of cost-effectiveness than vaccination. If the vaccine were applied with culling of seropositive tested dogs, then the measure became more effective with a reduced cost compared with the vaccine alone. The use of the three first consecutive vaccine doses had the greatest impact on the cost of the vaccination strategy. The advantage of using IICs is that there is no need for a prior diagnosis, unlike vaccination, reducing costs and facilitating implementation. The present study aims to contribute to strategies to reduce hosts infected with VL by reducing public expenditure.
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Affiliation(s)
- Anaiá da Paixão Sevá
- Department of Animal Health and Preventive Veterinary, University of São Paulo, São Paulo, São Paulo, Brazil
- Department of Exact and Technological Sciences, State University of Santa Cruz, Ilhéus, Brazil
- * E-mail: ,
| | - Fernando Ferreira
- Department of Animal Health and Preventive Veterinary, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Marcos Amaku
- Department of Animal Health and Preventive Veterinary, University of São Paulo, São Paulo, São Paulo, Brazil
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Sunyoto T, Boelaert M, Meheus F. Understanding the economic impact of leishmaniasis on households in endemic countries: a systematic review. Expert Rev Anti Infect Ther 2019; 17:57-69. [PMID: 30513027 DOI: 10.1080/14787210.2019.1555471] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/30/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Leishmaniasis is a poverty-related disease that causes a significant socioeconomic burden to affected households. Visceral leishmaniasis is fatal if untreated, yet illness costs may lead to delays in accessing care. Skin manifestations of leishmaniasis cause a psychological burden and even longer treatment trajectories. The objective of this review is to evaluate illness costs associated with leishmaniasis across different settings (Asia, Africa, and Latin America) and the consequences to households. Areas covered: Through a systematic review of cost-of-illness studies, we documented the distribution of costs, the health-seeking behavior, and the consequences of leishmaniasis. We discuss the value of cost-of-illness studies for leishmaniasis. Expert commentary: Despite the free provision of diagnostics and treatment in the public health care sector, out-of-pocket payments remain substantial. There has been progress in addressing the economic burden of leishmaniasis, particularly through the elimination initiative in the Indian subcontinent. Though the illness cost is decreasing due to shorter treatment regimens and better access to care, the situation remains challenging in Africa. Improvement of control tools is critical. There is a need to update cost estimates to inform policy-making and ensure sustainable solutions to reduce financial barriers to leishmaniasis care, especially in pursuing universal health coverage.
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Affiliation(s)
- Temmy Sunyoto
- a Public Health Department , Institute of Tropical Medicine , Antwerpen , Belgium
| | - Marleen Boelaert
- a Public Health Department , Institute of Tropical Medicine , Antwerpen , Belgium
| | - Filip Meheus
- b Early Detection and Prevention Section , International Agency for Research on Cancer , Lyon , France
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Coulborn RM, Gebrehiwot TG, Schneider M, Gerstl S, Adera C, Herrero M, Porten K, den Boer M, Ritmeijer K, Alvar J, Hassen A, Mulugeta A. Barriers to access to visceral leishmaniasis diagnosis and care among seasonal mobile workers in Western Tigray, Northern Ethiopia: A qualitative study. PLoS Negl Trop Dis 2018; 12:e0006778. [PMID: 30408042 PMCID: PMC6224040 DOI: 10.1371/journal.pntd.0006778] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/23/2018] [Indexed: 12/13/2022] Open
Abstract
Background Ethiopia bears a high burden of visceral leishmaniasis (VL). Early access to VL diagnosis and care improves clinical prognosis and reduces transmission from infected humans; however, significant obstacles exist. The approximate 250,000 seasonal mobile workers (MW) employed annually in northwestern Ethiopia may be particularly disadvantaged and at risk of VL acquisition and death. Our study aimed to assess barriers, and recommend interventions to increase access, to VL diagnosis and care among MWs. Methodology/Principal findings In 2017, 50 interviews and 11 focus group discussions were conducted with MWs, mobile residents, VL patients and caretakers, community leaders and healthcare workers in Kafta Humera District, Tigray. Participants reported high vulnerability to VL among MWs and residents engaged in transitory work. Multiple visits to health facilities were consistently needed to access VL diagnosis. Inadequate healthcare worker training, diagnostic test kit unavailability at the primary healthcare level, lack of VL awareness, insufficient finances for care-seeking and prioritization of income-generating activities were significant barriers to diagnosis and care. Social (decision-making and financial) support strongly and positively influenced care-seeking; workers unable to receive salary advances, compensation for partial work, or peer assistance for contract completion were particularly disadvantaged. Participants recommended the government/stakeholders intervene to ensure: MWs access to bed-nets, food, shelter, water, and healthcare at farms or sick leave; decentralization of diagnostic tests to primary healthcare facilities; surplus medications/staff during the peak season; improved referral/feedback/reporting/training within the health system; free comprehensive healthcare for all VL-related services; and community health education. Conclusions/Significance Contrary to what health policy for VL dictates in this endemic setting, study participants reported very poor access to diagnosis and, consequently, significantly delayed access to treatment. Interventions tailored to the socio-economic and health needs of MWs (and other persons suffering from VL) are urgently needed to reduce health disparities and the VL burden. Ethiopia bears a high burden of visceral leishmaniasis (VL)—a neglected tropical disease transmitted through the bite of a sand fly that disproportionately affects vulnerable populations. Without treatment, VL progresses, causing increasingly severe symptoms and ultimately death within two years, in most cases. Early access to VL diagnosis and care improves clinical prognosis and reduces transmission from infected humans; however, significant obstacles exist. To our knowledge, our study is the first in Ethiopia to use qualitative methods to assess barriers to VL diagnosis and care among seasonal mobile workers. Strikingly, we found that contrary to what health policy for VL dictates in this endemic setting, study participants reported very poor access to diagnosis and, consequently, significantly delayed access to treatment. Our findings have important public health and policy implications. Specifically, our results offer strategies that may increase access to VL diagnosis and care, allowing for earlier treatment and better prognoses for VL patients, and reducing the potential health disparities and the overall burden of VL.
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Affiliation(s)
| | | | | | | | | | - Mercè Herrero
- KalaCORE, London, United Kingdom
- World Health Organization, Geneva, Switzerland
| | | | - Margriet den Boer
- KalaCORE, London, United Kingdom
- Médecins Sans Frontières, London, United Kingdom
| | | | - Jorge Alvar
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Abrahim Hassen
- Department of Health Promotion and Disease Prevention, Tigray Regional Health Bureau, Tigray, Ethiopia
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Biswas S, Subramanian A, ELMojtaba IM, Chattopadhyay J, Sarkar RR. Optimal combinations of control strategies and cost-effective analysis for visceral leishmaniasis disease transmission. PLoS One 2017; 12:e0172465. [PMID: 28222162 PMCID: PMC5319670 DOI: 10.1371/journal.pone.0172465] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 02/06/2017] [Indexed: 11/29/2022] Open
Abstract
Visceral leishmaniasis (VL) is a deadly neglected tropical disease that poses a serious problem in various countries all over the world. Implementation of various intervention strategies fail in controlling the spread of this disease due to issues of parasite drug resistance and resistance of sandfly vectors to insecticide sprays. Due to this, policy makers need to develop novel strategies or resort to a combination of multiple intervention strategies to control the spread of the disease. To address this issue, we propose an extensive SIR-type model for anthroponotic visceral leishmaniasis transmission with seasonal fluctuations modeled in the form of periodic sandfly biting rate. Fitting the model for real data reported in South Sudan, we estimate the model parameters and compare the model predictions with known VL cases. Using optimal control theory, we study the effects of popular control strategies namely, drug-based treatment of symptomatic and PKDL-infected individuals, insecticide treated bednets and spray of insecticides on the dynamics of infected human and vector populations. We propose that the strategies remain ineffective in curbing the disease individually, as opposed to the use of optimal combinations of the mentioned strategies. Testing the model for different optimal combinations while considering periodic seasonal fluctuations, we find that the optimal combination of treatment of individuals and insecticide sprays perform well in controlling the disease for the time period of intervention introduced. Performing a cost-effective analysis we identify that the same strategy also proves to be efficacious and cost-effective. Finally, we suggest that our model would be helpful for policy makers to predict the best intervention strategies for specific time periods and their appropriate implementation for elimination of visceral leishmaniasis.
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Affiliation(s)
- Santanu Biswas
- Department of Mathematics, Adamas University, Barasat, Kolkata, India
| | - Abhishek Subramanian
- Chemical Engineering and Process Development, CSIR-National Chemical Laboratory, Dr. Homi Bhabha Road, Pune, 411008, India
- Academy of Scientific & Innovative Research (AcSIR), CSIR-NCL Campus, Pune - 411008, India
| | - Ibrahim M. ELMojtaba
- Department of Mathematics and Statistics, College of Science - Sultan Qaboos University, P.O. box - 36, Muscat, Oman
| | - Joydev Chattopadhyay
- Agricultural and Ecological Research Unit, Indian Statistical Institute, 203, B. T. Road, Kolkata, 700108, India
| | - Ram Rup Sarkar
- Chemical Engineering and Process Development, CSIR-National Chemical Laboratory, Dr. Homi Bhabha Road, Pune, 411008, India
- Academy of Scientific & Innovative Research (AcSIR), CSIR-NCL Campus, Pune - 411008, India
- * E-mail:
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Tachfouti N, Najdi A, Alonso S, Sicuri E, Laamrani El Idrissi A, Nejjari C, Picado A. Cost of Pediatric Visceral Leishmaniasis Care in Morocco. PLoS One 2016; 11:e0155482. [PMID: 27257808 PMCID: PMC4892465 DOI: 10.1371/journal.pone.0155482] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 04/29/2016] [Indexed: 11/19/2022] Open
Abstract
Background Visceral leishmaniasis (VL) is a neglected parasitic disease that is fatal if left untreated. VL is endemic in Morocco and other countries in North Africa were it mainly affects children from rural areas. In Morocco, the direct observation of Leishmania parasites in bone marrow aspirates and serological tests are used to diagnose VL. Glucantime is the first line of treatment. The objective of this study was to report the costs associated to standard clinical management of pediatric VL from the provider perspective in Morocco. As a secondary objective we described the current clinical practices and the epidemiological characteristics of pediatric VL patients. Methods From March to June 2014 we conducted a survey in eight hospitals treating pediatric VL patients in Morocco. A pro-forma was used to collect demographic, clinical and management data from medical records. We specifically collected data on VL diagnosis and treatment. We also estimated the days of hospitalization and the time to start VL treatment. Costs were estimated by multiplying the use of resources in terms of number of days in hospital, tests performed and drugs provided by the official prices. For patients receiving part of their treatment at Primary Health Centers (PHC) we estimated the cost of administering the Glucantime as outpatient. We calculated the median cost per VL patient. We also estimated the cost of managing a VL case when different treatment strategies were applied: inpatient and outpatient. Results We obtained data from 127 VL patients. The median total cost per pediatric VL case in Morocco is 520 US$. The cost in hospitals applying an outpatient strategy is significantly lower (307 US$) than hospitals keeping the patients for the whole treatment (636 US$). However the outpatient strategy is not yet recommended as VL treatment for children in the Moroccan guidelines. VL diagnosis and treatment regimens should be standardized following the current guidelines in Morocco.
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Affiliation(s)
- Nabil Tachfouti
- Laboratory of Epidemiology, clinical Research and Community Health, Faculty of Medicine and pharmacy of Fez, Sidi Mohamed Ben Abdellah University, Fez, Morocco
| | - Adil Najdi
- Laboratory of Epidemiology, clinical Research and Community Health, Faculty of Medicine and pharmacy of Fez, Sidi Mohamed Ben Abdellah University, Fez, Morocco
| | - Sergi Alonso
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Elisa Sicuri
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | | | - Chakib Nejjari
- Laboratory of Epidemiology, clinical Research and Community Health, Faculty of Medicine and pharmacy of Fez, Sidi Mohamed Ben Abdellah University, Fez, Morocco
- Ecole Nationale de Santé Publique (ENSP), Ministry of Health, Rabat, Morocco
| | - Albert Picado
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
- * E-mail:
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Marinho DS, Casas CNPR, Pereira CCDA, Leite IC. Health economic evaluations of visceral leishmaniasis treatments: a systematic review. PLoS Negl Trop Dis 2015; 9:e0003527. [PMID: 25723482 PMCID: PMC4344218 DOI: 10.1371/journal.pntd.0003527] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 01/09/2015] [Indexed: 11/19/2022] Open
Abstract
Visceral leishmaniasis (VL) is a severe form of the leishmaniasis-disease complex. Its importance to public health relies on its high fatality rate in non-treated cases, the socio-economic impact related to its morbidity, and its endemicity on different continents. The estimated burden of disease of VL varies from 1,969,000 to 2,357,000 Disability Adjusted Life Years (DALYs). VL is classified as a Neglected Tropical Disease (NTD), and is strongly related to poverty and its consequences. Visceral leishmaniasis calls for the development of cost-effective technologies for diagnosis and treatment. Visceral leishmaniasis (VL), also known as kala azar, is a neglected tropical disease caused by parasitic protozoa of the genus Leishmania. VL is related to poverty and its consequences, which leads to its status of neglected disease. For that reason, cost-effective forms of diagnoses and treatment are very important and still needed. This research aimed at a better understanding of the publications about the technologies currently available, from the standpoint of their economic value. For that purpose, we conducted a systematic review of the literature in order to identify the papers that conducted economic evaluations of technologies used in VL. We initially retrieved 107 articles, which were inspected according to specific guidelines for systematic reviews. After that process, 14 articles matched the inclusion criteria in our review. We classified those studies according to the type of economic evaluation they made, and the methodology used in each one. We found evaluations about a variety of technologies, but the studies were geographically concentrated in Asia, more specifically in India. This concentration is not good because the disease also affects other continents and it is not possible to transfer the economic evaluation from one country or epidemiologic scenario to another.
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Affiliation(s)
- Daniel S. Marinho
- Centro de Desenvolvimento Tecnológico em Saúde, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
- Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
- National Institute for Science and Technology on Innovation on Neglected Diseases (INCT/IDN), Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Carmen N. P. R. Casas
- Centro de Desenvolvimento Tecnológico em Saúde, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
- National Institute for Science and Technology on Innovation on Neglected Diseases (INCT/IDN), Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | | | - Iuri C. Leite
- Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
- * E-mail:
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Abstract
Visceral leishmaniasis (kala-azar) is a disseminated intracellular protozoal infection. Most cases (90%) occur in the rural regions of five countries: India, Sudan, Nepal, Bangladesh and Brazil. As with other infectious diseases embedded in high-level poverty, developing and/or delivering new treatments for visceral leishmaniasis had been painfully slow or nonexistent. However, despite persistent unresolved obstacles (e.g., drug affordability), renewed interest in visceral leishmaniasis and numerous successful treatment trials have combined to turn a therapeutic corner in the past 5 years, yielding new alternatives to conventional pentavalent antimony. Advances include the use of low-cost generic pentavalent antimony, rediscovery of amphotericin B, short-course regimens via lipid formulations of amphotericin B, retesting injectible paromyomycin and, of clear-cut importance, identifying miltefosine (Impavido, Zentaris) as the first effective oral therapy for this neglected disease.
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Affiliation(s)
- Henry W Murray
- Department of Medicine, Weill Medical College of Cornell University, 1300 York Avenue, New York, NY 10021, USA.
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Meheus F, Abuzaid AA, Baltussen R, Younis BM, Balasegaram M, Khalil EAG, Boelaert M, Musa AM. The economic burden of visceral leishmaniasis in Sudan: an assessment of provider and household costs. Am J Trop Med Hyg 2013; 89:1146-1153. [PMID: 24189368 PMCID: PMC3854893 DOI: 10.4269/ajtmh.12-0585] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Visceral leishmaniasis (VL) is a neglected parasitic disease that is fatal if left untreated and is endemic in eastern Sudan. We estimated the direct and indirect costs of treatment of VL from the perspective of the provider and the household at three public hospitals in Gedaref State. The median total cost for one VL episode was estimated to be US$450. Despite the free provision of VL drugs at public hospitals, households bore 53% of the total cost of VL with one episode of VL representing 40% of the annual household income. More than 75% of households incurred catastrophic out-of-pocket expenditures. The length of treatment of 30 days led to important costs for both health providers and households. Alternative treatment regimens that reduce the duration of treatment are urgently needed.
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Affiliation(s)
- Filip Meheus
- *Address correspondence to Filip Meheus, Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory 7925, South Africa. E-mail:
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Strømme EM, Baerøe K, Norheim OF. Disease control priorities for neglected tropical diseases: lessons from priority ranking based on the quality of evidence, cost effectiveness, severity of disease, catastrophic health expenditures, and loss of productivity. Dev World Bioeth 2013; 14:132-41. [PMID: 23724925 DOI: 10.1111/dewb.12016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND In the context of limited health care budgets in countries where Neglected Tropical Diseases (NTDs) are endemic, scaling up disease control interventions entails the setting of priorities. However, solutions based solely on cost-effectiveness analyses may lead to biased and insufficiently justified priorities. OBJECTIVES The objectives of this paper are to 1) demonstrate how a range of equity concerns can be used to identify feasible priority setting criteria, 2) show how these criteria can be fed into a multi-criteria decision-making matrix, and 3) discuss the conditions under which this decision-making procedure should be carried out in a real-world decision-making context. METHODS This paper draws on elements from theories of decision analysis and ethical theories of fair resource allocation. We explore six typical NTD interventions by employing a modified multi-criteria decision analysis model with predefined criteria, drawn from a priority setting guide under development by the WHO. To identify relevant evidence for the six chosen interventions, we searched the PubMed and Cochrane databases. DISCUSSION Our in vitro multi-criteria decision analysis suggested that case management for visceral leishmaniasis should be given a higher priority than mass campaigns to prevent soil-transmitted helminthic infections. This seems to contradict current health care priorities and recommendations in the literature. We also consider procedural conditions that should be met in a contextualised decision-making process and we stress the limitations of this study exercise. CONCLUSION By exploring how several criteria relevant to the multi-facetted characteristics of NTDs can be taken into account simultaneously, we are able to suggest how improved priority settings among NTDs can be realised.
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Adhikari SR. An assessment of a substitute or complement for inpatient and outpatient care of visceral leishmaniasis in Nepal. J Vector Borne Dis 2012; 49:242-248. [PMID: 23428524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND & OBJECTIVES The burden of visceral leishmaniasis (VL) in Nepal, as in other developing countries, falls disproportionately upon the rural poor. Promoting use of outpatient (OP) care, an alternative to inpatient (IP) care has long been advocated to reduce cost of care in both the demand and supply sides as substitution of relatively cheaper resources for expensive resources in the production of health care services. The paper aims to assess the intensity of demand for VL care and explore possibilities of the substitutability or complementation patterns between OP care and IP care of VL. METHODS In order to explore the possibility of substitute (or complement) of OP care for IP care, we exploited the ordinary least squared method by utilizing recently collected data from the VL endemic districts of Nepal. The sample size represented > 25% of the population of VL of the country. The paper measured the sensitivity analysis of demand for OP and IP cares using appropriate demand models. RESULTS The coefficients of demand models gave negative relationship between quantity demanded for health care and their prices. It is plausible that OP price has strong power than IP price to determine the respective quantity demanded for health care. As expected, income has negative sign, but not significant that means income has no effect on determining the demand for health care because VL is a disease of poor. CONCLUSION Recently, improvements in treatment and diagnostic techniques suggest a substitute of OP care for IP care; however, the OP and IP cares are complements due to behavioural factors.
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Affiliation(s)
- Shiva Raj Adhikari
- Patan Multiple Campus, Department of Economics, Patan Dhoka Lalitpur, Nepal.
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Sheets D, Mubayi A, Kojouharov HV. Impact of socio-economic conditions on the incidence of visceral leishmaniasis in Bihar, India. Int J Environ Health Res 2010; 20:415-430. [PMID: 21161803 DOI: 10.1080/09603123.2010.491853] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Visceral leishmaniasis (VL) is one of the world's worst parasitic killers, second only to Malaria, claiming thousands of lives every year. More than three fifths of the world's VL cases occur in the Indian state of Bihar alone. While some research has been conducted with emphasis on the effects of climatic variables on the VL incidence rate, rigorous analysis of the effects of socio-economic variables is still lacking. In this paper a regression model is developed that describes the relationship between VL incidence rate and a variety of socio-economic factors. It uses data from 2005 and explains 92% of the observed variance. In addition, a stepwise regression model is also used to identify the most important factors that facilitate the prevalence of the VL disease. A discussion on how to most effectively distribute Bihar's limited resources on various control measures to decrease the incidence of VL is also presented.
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Affiliation(s)
- Darren Sheets
- Department of Economics, University of Texas at Arlington, Arlington, Texas 76019 0479, USA
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Meheus F, Balasegaram M, Olliaro P, Sundar S, Rijal S, Faiz MA, Boelaert M. Cost-effectiveness analysis of combination therapies for visceral leishmaniasis in the Indian subcontinent. PLoS Negl Trop Dis 2010; 4. [PMID: 20838649 PMCID: PMC2935395 DOI: 10.1371/journal.pntd.0000818] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Accepted: 08/12/2010] [Indexed: 11/20/2022] Open
Abstract
Background Visceral leishmaniasis is a systemic parasitic disease that is fatal unless treated. We assessed the cost and cost-effectiveness of alternative strategies for the treatment of visceral leishmaniasis in the Indian subcontinent. In particular we examined whether combination therapies are a cost-effective alternative compared to monotherapies. Methods and Findings We assessed the cost-effectiveness of all possible mono- and combination therapies for the treatment of visceral leishmaniasis in the Indian subcontinent (India, Nepal and Bangladesh) from a societal perspective using a decision analytical model based on a decision tree. Primary data collected in each country was combined with data from the literature and an expert poll (Delphi method). The cost per patient treated and average and incremental cost-effectiveness ratios expressed as cost per death averted were calculated. Extensive sensitivity analysis was done to evaluate the robustness of our estimations and conclusions. With a cost of US$92 per death averted, the combination miltefosine-paromomycin was the most cost-effective treatment strategy. The next best alternative was a combination of liposomal amphotericin B with paromomycin with an incremental cost-effectiveness of $652 per death averted. All other strategies were dominated with the exception of a single dose of 10mg per kg of liposomal amphotericin B. While strategies based on liposomal amphotericin B (AmBisome) were found to be the most effective, its current drug cost of US$20 per vial resulted in a higher average cost-effectiveness. Sensitivity analysis showed the conclusion to be robust to variations in the input parameters over their plausible range. Conclusions Combination treatments are a cost-effective alternative to current monotherapy for VL. Given their expected impact on the emergence of drug resistance, a switch to combination therapy should be considered once final results from clinical trials are available. Visceral leishmaniasis (VL) is a serious health problem in the Indian subcontinent affecting the rural poor. It has a significant economic impact on concerned households. The development of drug resistance is a major problem and threatens control efforts under the VL elimination initiative. With an unprecedented choice of antileishmanial drugs (but no newer compound in clinical development), policies that protect these drugs against the emergence of resistance are required. A possible strategy that has been successfully used for malaria and tuberculosis is the use of combination therapies. This study is the first comprehensive assessment of the cost-effectiveness of all possible mono- and combination therapies for the treatment of visceral leishmaniasis in the Indian subcontinent. The analysis was done from the societal perspective, including both health provider and household costs. The present work shows that combination treatments are a cost-effective alternative to current monotherapy for VL. Given their expected impact on emergence of drug resistance, the use of combination therapy should be considered in the context of the VL elimination programme in the Indian subcontinent.
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Affiliation(s)
- Filip Meheus
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
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Adhikari SR, Supakankunti S. A cost benefit analysis of elimination of kala-azar in Indian subcontinent: an example of Nepal. J Vector Borne Dis 2010; 47:127-139. [PMID: 20834081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND & OBJECTIVES Visceral leishmaniasis, locally known as kala-azar (KA) has been considered as a major public health problem in Bangladesh, India and Nepal that affects 100,000 people per year with 147 million people at risk. Elimination of infectious disease is an ultimate goal of the public health system, therefore, the efforts have recently gained momentum from various organizations and governments to expand KA interventions in the endemic countries. The paper aims to estimate discounted net benefits and internal rate of return (IRR) to evaluate the economic feasibility for elimination of KA by utilizing available secondary information. METHODS Cross-sectional data were collected from different sources to estimate societal costs of and benefits from KA interventions with a 13-year project period. Total costs are estimated based on the unit cost of inputs used for interventions. The benefits are derived from productivity change and resources saved due to reduction of KA incidence. Net benefits and IRRs are estimated based on standard procedures used in the field of economics, subsequently the sensitivity analysis is conducted. RESULTS A total discounted net benefit of KA intervention is Nepalese Rupees (NRs) 65,287 million with 35% IRR. The result suggests that for every rupee invested in KA intervention at present will yield NRs 71 in future. The regional benefits from the interventions will be greater than the sum of benefits gained by the individual country due to its nature of public goods. CONCLUSION Elimination of KA is a good investment opportunity for the Government and international partners involved in the health sector.
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Affiliation(s)
- Shiva Raj Adhikari
- Faculty of Economics, Centre for Health Economics, Chulalongkorn University, Thailand.
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Patnaik MM, Stauffer WM, Campagna A, Stauffer CI, Walker PF. When the market fails, the poor pay. Minn Med 2007; 90:38-40. [PMID: 17432756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
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18
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Vanlerberghe V, Diap G, Guerin PJ, Meheus F, Gerstl S, Van der Stuyft P, Boelaert M. Drug policy for visceral leishmaniasis: a cost-effectiveness analysis. Trop Med Int Health 2007; 12:274-83. [PMID: 17300636 DOI: 10.1111/j.1365-3156.2006.01782.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To facilitate the choice of the best visceral leishmaniasis (VL) treatment strategy for first-line health services in (VL)-endemic areas, we compared in a formal decision analysis the cost and the cost-effectiveness of the different available options. METHODS We selected four drug regimens for VL on the basis of frequency of use, feasibility and reported efficacy studies. The point estimates and the range of plausible values of effectiveness and cost were retrieved from a literature review. A decision tree was constructed and the strategy minimizing the cost per death averted was selected. RESULTS Treatment with amphotericin B deoxycholate was the most effective approach in the baseline analysis and averted 87.2% of all deaths attributable to VL. The least expensive and the most cost-effective treatment was the miltefosine regimen, and the most expensive and the least cost-effective was AmBisome treatment. The cost of drug and medical care are the main determinants of the cost-effectiveness ranking of the alternative schemes. Sensitivity analysis showed that antimonial was competitive with miltefosine in the low-resistance regions. CONCLUSION In areas with >94% response rates to antimonials, generic sodium stibogluconate remains the most cost-effective option for VL treatment, mainly due to low drug cost. In other regions, miltefosine is the most cost-effective option of treatment, but its use as a first-line drug is limited by its teratogenicity and rapid resistance development. AmBisome in mono- or combination therapy is too expensive to compete in cost-effectiveness with the other regimens.
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Affiliation(s)
- V Vanlerberghe
- Epidemiology and Disease Control Unit, Prince Leopold Institute of Tropical Medicine, Antwerp, Belgium.
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Abstract
OBJECTIVES To identify and quantify the direct and indirect economic cost of treatment for visceral leishmaniasis (VL) with conventional Amphotericin B deoxycholate, currently the first-line treatment in Muzaffarpur. METHODS Costs of patient management for VL were estimated from a societal and household perspective by means of a questionnaire designed for this study, interviews and financial reports. RESULTS The total cost of care per episode of VL from the societal perspective was estimated at US$355, equivalent to 58% of annual household income. The largest cost category was medical costs (55%), followed by indirect costs (36%) and non-medical costs (9%). The cost from the household perspective was equivalent to US$217. The largest cost category was indirect costs (59%), followed by medical costs (27%) and non-medical costs (15%). Loss of income because of illness and hospitalization and expenses for drugs were the largest cost components. CONCLUSIONS The economic costs related to VL are substantial, both to society and the patient. Public health authorities in Bihar should focus on policies that detect VL in the early stage and implement interventions that minimize the burden to households affected by VL.
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Affiliation(s)
- Filip Meheus
- Institute of Development Policy and Management, University of Antwerp, Antwerp, Belgium.
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Abstract
Leishmaniasis, a neglected tropical disease, has strong but complex links with poverty. The burden of leishmaniasis falls disproportionately on the poorest segments of the global population. Within endemic areas, increased infection risk is mediated through poor housing conditions and environmental sanitation, lack of personal protective measures and economically driven migration and employment that bring nonimmune hosts into contact with infected sand flies. Poverty is associated with poor nutrition and other infectious diseases, which increase the risk that a person (once infected) will progress to the clinically manifested disease. Lack of healthcare access causes delays in appropriate diagnosis and treatment and accentuates leishmaniasis morbidity and mortality, particularly in women. Leishmaniasis diagnosis and treatment are expensive and families must sell assets and take loans to pay for care, leading to further impoverishment and reinforcement of the vicious cycle of disease and poverty. Public investment in treatment and control would decrease the leishmaniasis disease burden and help to alleviate poverty.
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Affiliation(s)
- Jorge Alvar
- Communicable Diseases, Neglected Tropical Diseases Control, World Health Organization, 20 Ave Appia, CH-1211 Geneva 27, Switzerland.
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Abstract
This review summarizes the current developments in therapy for visceral leishmaniasis. With the recent introduction of new drugs, the main limits in reducing deaths from visceral leishmaniasis are difficulty in diagnosis in the field and health inequality--patients lack of access to treatment. No new drugs are currently in the early stages of development. There are good reasons for the use of combination therapy; to prevent further development of resistance against the limited therapeutic options available.
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Affiliation(s)
- Margriet den Boer
- Campaign for Access to Essential Medicines, Médecins Sans Frontières, Rue Lausanne 78 CP 116 CH-1211, Geneva 21, Switzerland.
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Ozsoylu S. Treatment of visceral leishmaniasis. Pediatr Hematol Oncol 2006; 23:449-51; author reply 455-7. [PMID: 16728366 DOI: 10.1080/08880010600642810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Anoopa Sharma D, Bern C, Varghese B, Chowdhury R, Haque R, Ali M, Amann J, Ahluwalia IB, Wagatsuma Y, Breiman RF, Maguire JH, McFarland DA. The economic impact of visceral leishmaniasis on households in Bangladesh. Trop Med Int Health 2006; 11:757-64. [PMID: 16640630 DOI: 10.1111/j.1365-3156.2006.01604.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To explore current patterns of diagnosis and treatment, quantify household economic impact and identify household strategies to cover the costs of visceral leishmaniasis (VL) care in rural Bangladesh. METHOD Structured interviews with 113 VL patients from 87 households documenting all provider visits and expenditures for health care for VL, and the ways in which the expenditures were covered. RESULTS Patients paid a median of 7 visits to six different providers before beginning VL treatment. All visited the subdistrict government hospital at least once. While health care, including antileishmanial drug therapy, is officially available free of charge at government facilities, 79% of patients reported making informal payments for provider access, diagnostics and drug administration; only 14% of patients received their full drug course from this source. For the 58% of patients who purchased the full treatment course, drug cost constituted 34% of direct expenditure. Median direct expenditure for one VL patient was US$87 and median income lost was $40; median total expenditure was 1.2 times annual per capita income of our study population. Households employed multiple coping strategies to cover expenditures, most commonly sale or rental of assets (62%) and taking out loans (64%). CONCLUSIONS Visceral leishmaniasis treatment causes a major economic burden in affected families. Control strategies for VL should facilitate timely, affordable diagnosis and treatment of patients to decrease the infection reservoir and to alleviate the economic burden of VL on households.
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Affiliation(s)
- D Anoopa Sharma
- Emory University Rollins School of Public Health, Atlanta, GA, USA
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Abstract
The Leishmania donovani complex includes L. chagasi and L. infantum, and causes visceral leishmaniasis (VL), a disseminated and potentially fatal form of leishmaniasis. The treatment options for VL are limited. Pentavalent antimonials (Sbv) are the first-line treatment options worldwide except for in Europe and Sbv-unresponsive regions of India. Amphotericin B deoxycholate is the drug of choice in India, as are its lipid formulations in Europe. However, liposomal amphotericin B (AmBisome, Gilead Sciences, Inc.) is the best antileishmanial formulation, but its prohibitive cost limits its use in endemic countries. Preferential pricing of AmBisome for patients with VL may provide hope for these underprivileged patients. Oral miltefosine and paromomycin are the other drugs that have been recently developed. Limited therapeutic options, the potential for development of resistance and serious toxicity associated with antileishmanial drugs necessitates a change in the treatment policy. A shift from monotherapy to multi-drug combinations of short courses delivered at no or affordable cost, through directly observed therapy, seems to be the only way to develop the treatment of this disease.
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Affiliation(s)
- Shyam Sundar
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005, India.
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Rijal S, Koirala S, Van der Stuyft P, Boelaert M. The economic burden of visceral leishmaniasis for households in Nepal. Trans R Soc Trop Med Hyg 2006; 100:838-41. [PMID: 16406035 DOI: 10.1016/j.trstmh.2005.09.017] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2005] [Revised: 09/18/2005] [Accepted: 09/19/2005] [Indexed: 10/25/2022] Open
Abstract
Visceral leishmaniasis (VL) affects persons from the lowest socioeconomic strata of the community, but its economic impact is not precisely known. An exploratory survey to document the economic costs of VL to households was conducted in an endemic focus in eastern Nepal. Data were collected from the 20 households in this cluster. Cases of VL over the last 3 years were elicited and information on direct and indirect costs incurred due to the disease as well as income of the households over the last year was estimated. It was reported that 15.0% (16/107) of the residents had suffered from VL and that almost all of the patients had preferred, in the first instance, to visit the private services or local faith healers instead of visiting the local public health facility. Average total costs incurred per episode of VL were above the median annual per capita income, and six of the seven affected households either had to sell part of their livestock or to take a loan to cover the costs. Direct costs consisted of 53% of the total cost, with 75% of this cost incurred before the patients actually received any treatment for VL. This study demonstrates how VL can lead to catastrophic expenditure for affected households.
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Affiliation(s)
- S Rijal
- Department of Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal.
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Cowley G. Your health in the 21st century. Chasing black fever. Newsweek 2005; 145:60-4. [PMID: 16375149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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Abstract
Leishmaniasis represents a complex of diseases with an important clinical and epidemiological diversity. Visceral leishmaniasis (VL) is of higher priority than cutaneous leishmaniasis (CL) as it is a fatal disease in the absence of treatment. Anthroponotic VL foci are of special concern as they are at the origin of frequent and deathly epidemics (e.g. Sudan). Leishmaniasis burden remains important: 88 countries, 350 million people at risk, 500,000 new cases of VL per year, 1-1.5 million for CL and DALYs: 2.4 millions. Most of the burden is concentrated on few countries which allows clear geographic priorities. Leishmaniasis is still an important public health problem due to not only environmental risk factors such as massive migrations, urbanisation, deforestation, new irrigation schemes, but also to individual risk factors: HIV, malnutrition, genetic, etc em leader Leishmaniasis is part of those diseases which still requires improved control tools. Consequently WHO/TDR research for leishmaniasis has been more and more focusing on the development of new tools such as diagnostic tests, drugs and vaccines. The ongoing effort has already produced significant results. The newly available control tools should allow a scaling up of control activities in priority areas. In anthroponotic foci, the feasibility of getting a strong impact on mortality, morbidity and transmission, is high.
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Affiliation(s)
- P Desjeux
- Department of Control, Prevention and Elimination (CDS/CPE), Cluster of Communicable Diseases, World Health Organization (WHO), Avenue Appia, 1211 Geneva 27, Switzerland.
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Ahluwalia IB, Bern C, Costa C, Akter T, Chowdhury R, Ali M, Alam D, Kenah E, Amann J, Islam M, Wagatsuma Y, Haque R, Breiman RF, Maguire JH. Visceral leishmaniasis: consequences of a neglected disease in a Bangladeshi community. Am J Trop Med Hyg 2003; 69:624-8. [PMID: 14740879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023] Open
Abstract
Visceral leishmaniasis, or kala azar (KA), affects the rural poor, causing significant morbidity and mortality. We examined the epidemiologic, social, and economic impact of KA in a village in Bangladesh. A population-based survey among 2,348 people demonstrated a KA incidence of 2% per year from 2000 to 2002, with a case-fatality rate of 19% among adult women, compared with 6-8% among other demographic groups. Kala azar cases were geographically clustered in certain sections of the village. Anti-leishmanial drug shortages and the high cost of diagnosis and treatment caused substantial emotional and economic hardship for affected families. Communities wanted to learn more about KA, and were willing to take collective action to confront the problems it causes. To decrease the KA burden in endemic areas, community efforts should be supplemented with effective treatment programs to ensure access to appropriate and affordable diagnosis and case management.
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Affiliation(s)
- Indu B Ahluwalia
- Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia 30341, USA
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Abstract
Conditional on correct diagnosis and treatment, current drug regimens for visceral leishmaniasis (VL) will only prevent about 90% of deaths. Furthermore, the cost of pentavalent antimonials, the long duration of the regimen and its parenteral administration are major obstacles for patients. Poor patient compliance and the use of counterfeit drugs contribute to therapeutic failure, amplification of the reservoir and the appearance of drug resistance. We assessed the impact of potential improvements in chemotherapy on the cost-effectiveness of VL test-treatment strategies. Competing test-treatment strategies were compared in a formal decision analysis - from the viewpoint of the clinician facing a VL suspect -, with avoided VL-mortality and cost as outcomes of interest. Sensitivity analysis was done involving the following parameters: efficacy, toxicity and cost of treatment including patient care. When safer and more efficacious drugs are considered, they only result in a more cost-effective strategy if the total cost of treatment falls below US$ 390 per patient. A serological test-treatment strategy remains the optimal choice, also when better drugs become available.
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Affiliation(s)
- M Boelaert
- Prince Leopold Institute of Tropical Medicine, Antwerp, Belgium.
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Affiliation(s)
- A Bryceson
- London School of Hygiene and Tropical Medicine, UK.
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Griekspoor A, Sondorp E, Vos T. Cost-effectiveness analysis of humanitarian relief interventions: visceral leishmaniasis treatment in the Sudan. Health Policy Plan 1999; 14:70-6. [PMID: 10351471 DOI: 10.1093/heapol/14.1.70] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Spending by aid agencies on emergencies has quadrupled over the last decade, to over US$6 billion. To date, cost-effectiveness has seldom been considered in the prioritization and evaluation of emergency interventions. The sheer volume of resources spent on humanitarian aid and the chronicity of many humanitarian interventions call for more attention to be paid to the issue of 'value for money'. In this paper we present data from a major humanitarian crisis, an epidemic of visceral leishmaniasis (VL) in war-torn Sudan. The special circumstances provided us, in retrospect, with unusually accurate data on excess mortality, costs of the intervention and its effects, thus allowing us to express cost-effectiveness as the cost per Disability Adjusted Life Year (DALY) averted. The cost-effectiveness ratio, of US$18.40 per DALY (uncertainty range between US$13.53 and US$27.63), places the treatment of VL in Sudan among health interventions considered 'very good value for money' (interventions of less than US$25 per DALY). We discuss the usefulness of this analysis to the internal management of the VL programme, the procurement of funds for the programme, and more generally, to priority setting in humanitarian relief interventions. We feel that in evaluations of emergency interventions attempts could be made more often to perform cost-effectiveness analyses, including the use of DALYs, provided that the outcomes of these analyses are seen in the broad context of the emergency situation and its consequences on the affected population. This paper provides a first contribution to what is hoped to become an international database of cost-effectiveness studies of health interventions during relief operations, which use a comparable measure of health outcome such as the DALY.
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Affiliation(s)
- A Griekspoor
- Médecins Sans Frontières, Amsterdam, The Netherlands
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Boelaert M, Lynen L, Desjeux P, Van der Stuyft P. Cost-effectiveness of competing diagnostic-therapeutic strategies for visceral leishmaniasis. Bull World Health Organ 1999; 77:667-74. [PMID: 10516788 PMCID: PMC2557711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
Reported are the results of a formal decision analysis which facilitated the choice of the most appropriate test-treatment strategy for visceral leishmaniasis in areas where the disease is endemic. The following strategies were compared: treatment of all suspects (strategy A); testing by means of parasitological investigation followed by treatment of positives (strategy B); two-step testing by means of the direct agglutination test (DAT) followed by treatment of patients with high titres as well as those with parasitologically confirmed borderline titres (strategy C); and DAT followed by treatment of positives (strategy D). The results for each strategy were expressed as costs in US$ per death averted. The effectiveness of strategies C and D was close to that of strategy A and far better than that of strategy B. The cost-effectiveness ratio for strategies C and D (US$ 465 per death averted) was not substantially higher than that of testing by means of parasitological investigation followed by treatment of positives (strategy B), which was the most cost-effective strategy at US$448 per death averted. At current prices of antimonial drugs, the cost of test-treatment strategies depends more on the cost of treatment than on that of testing. The use of a sensitive serological test such as the DAT is recommended as the basis of test-treatment strategies for visceral leishmaniasis in areas where the disease is endemic.
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Affiliation(s)
- M Boelaert
- Unit of Epidemiology, Institute of Tropical Medicine, Antwerp, Belgium
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Sundar S, Goyal AK, More DK, Singh MK, Murray HW. Treatment of antimony-unresponsive Indian visceral leishmaniasis with ultra-short courses of amphotericin-B-lipid complex. Ann Trop Med Parasitol 1998; 92:755-64. [PMID: 9924533 DOI: 10.1080/00034989858998] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
High cost is the principal drawback of treating visceral leishmaniasis (VL; kala-azar) with any of the new lipid formulations of amphotericin B. The aim of the present study was to see if the costs of treatment with such drugs could be reduced by using ultra-short courses. Amphotericin-B-lipid complex (ABLC) was given to 77 Indian patients with antimony-unresponsive VL, either as a single infusion of 5 mg/kg (Group A) or two infusions, each of 5 mg/kg, given 5 days apart (Group B) or on consecutive days (Group C). Other than the anticipated higher fever and chills, treatment was well-tolerated. On day 19 after first infusion, 72 patients were considered apparent cures: 24 (89%) of the 27 in Group A; all 24 (100%) in Group B; and 24 (92%) of the 26 patients in Group C. Six months after treatment, 19 (70%) of 27 in Group A, 19 (79%) of 24 in Group B, and 21 (81%) of 26 in Group C were healthy, relapse-free and considered definitive cures. These cure rates were not statistically different. All 18 treatment failures (five initial non-responders and 13 relapses) were cured after treatment with a 5-day course of ABLC at a higher dose (10-15 mg/kg.day). In a related analysis of hospital plus drug costs for treating antimony-unresponsive VL, short-course ABLC (1-5 days) was compared with conventional amphotericin B (0.75-1.0 mg/kg on alternate days over 30-34 days). This analysis, which included the cost of re-treatment, identified one short-course ABLC regimen with an overall estimated expense which was only modestly higher than that of amphotericin B. Together, the present results provide further support for the use of ABLC in the management of VL patients who fail antimony therapy.
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Affiliation(s)
- S Sundar
- Kala-azar Medical Research Center, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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37
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Abstract
Incorporation of amphotericin B into small unilamellar liposomes (AmBisome) alters the pharmacokinetic properties of the drug, but allows it to retain significant in vitro and in vivo activity against fungal species, including Candida, Aspergillus and Cryptococcus, and parasites of the genus Leishmania. Used as prophylaxis against fungal infections in immunocompromised patients, liposomal amphotericin B appeared to reduce the incidence of both fungal colonisation and proven fungal infections, but did not affect overall survival. Empirical therapy with liposomal amphotericin B in immunocompromised adults or children with suspected fungal infections was at least as effective as therapy with conventional amphotericin B. In the largest noncomparative studies, liposomal amphotericin B produced mycological eradication in 40 and 83% of patients with proven Candida infections and 41 and 60% with proven Aspergillus infections; however, these studies included relatively few patients. Mycological eradication rates of 67 to 85% in patients with cryptococcal meningitis have been reported. Liposomal amphotericin B is an effective treatment for visceral leishmaniasis in immunocompetent adults and children, including those with severe or drug-resistant disease. The drug also produces good response rates in immunocompromised patients; however, relapse rates in these patients are high. Liposomal amphotericin B is generally well tolerated. Few patients require discontinuation or dose reduction of the drug because of adverse events. The most frequently reported adverse events are hypokalaemia, nephrotoxicity and infusion-related reactions; however, these occur significantly less often after liposomal amphotericin B than after the conventional formulation of the drug. The acquisition cost of liposomal amphotericin B is higher than that of conventional amphotericin B. Cost-effectiveness analysis did not clearly show an economic benefit for empirical liposomal amphotericin B antifungal therapy in adults; however, one model suggested that initial empirical therapy with the liposomal formulation in children may cost less per cure than initial therapy with the conventional formulation. Liposomal amphotericin B appears to be an effective alternative to conventional amphotericin B in the management of immunocompromised patients with proven or suspected fungal infections. Use of the drug is facilitated by its greatly improved tolerability profile compared with conventional amphotericin B. Because of this, liposomal amphotericin should be preferred to conventional amphotericin B in the management of suspected or proven fungal infections in immunocompromised patients with pre-existing renal dysfunction, amphotericin B-induced toxicity or failure to respond to conventional amphotericin B. Liposomal amphotericin B may also be considered for first- or second-line treatment of immunocompetent patients with visceral leishmaniasis.
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Affiliation(s)
- A J Coukell
- Adis International Limited, Auckland, New Zealand
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Thakur CP, Sinha GP, Pandey AK, Barat D, Singh RK. Daily versus alternate-day regimen of amphotericin B in the treatment of kala-azar: a randomized comparison. Bull World Health Organ 1994; 72:931-6. [PMID: 7867139 PMCID: PMC2486723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Using a randomized study, we compared a daily and an alternate-day regimen of amphotericin B for the treatment of kala-azar, with respect to efficacy, adverse reactions, cost-effectiveness, and tolerance. The study subjects were 80 kala-azar patients, drawn from the first four decades of life and matched by age, sex, and parasite load. The patients were randomly allocated to treatment groups A and B (40 patients per group). Patients in group A received a daily regimen of amphotericin B, starting with an escalating dose of 0.05 mg/kg body weight per day until a daily dose of 1 mg/kg was reached; the latter dose was then given daily till a total dose of 20 mg/kg body weight had been administered. The patients in group B also started with an escalating dose of 0.05 mg/kg but when 1 mg/kg was reached the drug was given on alternate days. All 80 patients using the two treatment regimens were cured, no patient relapsed in either group in 6 months of follow-up, and their bone-marrow aspirates were free of amastigotes. Treatment of kala-azar patients with the daily regimen of amphotericin B at a dose 1 mg/kg body weight was as effective, not more toxic, equally well tolerated, and much more cost-effective than the alternate-day regimen and should be adopted for treatment of this condition.
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Affiliation(s)
- C P Thakur
- Patna Medical College and Hospital, Bihar, India
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Chunge CN, Owate J, Pamba HO, Donno L. Treatment of visceral leishmaniasis in Kenya by aminosidine alone or combined with sodium stibogluconate. Trans R Soc Trop Med Hyg 1990; 84:221-5. [PMID: 2167522 DOI: 10.1016/0035-9203(90)90263-e] [Citation(s) in RCA: 124] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The treatment of leishmaniasis, as currently conducted in Kenya with sodium stibogluconate, is unsatisfactory as it is expensive, resistance and relapses may occur, and major adverse effects have been reported. Recently, aminosidine (paromomycin) sulphate has shown good antileishmanial activity on its own as well as synergism with pentavalent antimony, administered concurrently. The present study was designed to assess the effectiveness of parenteral aminosidine, alone or combined with sodium stibogluconate, in visceral leishmaniasis, compared to treatment by stibogluconate alone. 53 patients were allocated to the 3 therapeutic regimes. The presenting signs and symptoms of leishmaniasis were those commonly seen in the visceral form of the disease, particularly in Kenya. At termination, clinical cures were achieved in all 53 patients with no difference between treatment groups. Spleen aspirates revealed the best parasitological results in patients receiving the combined treatment, with only 13% failures (partial cures + relapses), as opposed to 21% failures with aminosidine alone and 45% with stibogluconate alone. Treatment with aminosidine alone was the cheapest and safest regime.
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Affiliation(s)
- C N Chunge
- Department of Medical Microbiology and Medical Pharmacology, College of Health Sciences, University of Nairobi, Kenya
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Rao LS. Liposomal dosage form development--some practical considerations. J Parenter Sci Technol 1983; 37:72-5. [PMID: 6308198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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