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Treatment of chloroquine-resistant malaria in African children: a cost-effectiveness analysis
P Sudre1, J G Breman, D McFarland
1Malaria Branch, Centers for Disease Control, Atlanta, GA 30333.
Insights
Chloroquine-resistant Plasmodium falciparum necessitates evaluating alternative malaria treatments. Pyrimethamine-sulfadoxine (PS) becomes more cost-effective than amodiaquine (Aq) or chloroquine (Cq) when resistance exceeds 14-31%.
Area of Science:
- Malariology
- Pharmacoeconomics
- Public Health
Background:
- Chloroquine-resistant Plasmodium falciparum (CRPF) is prevalent in Africa, impacting malaria treatment efficacy.
- Assessing alternative antimalarial drugs like amodiaquine (Aq) and pyrimethamine-sulfadoxine (PS) is crucial.
Purpose of the Study:
- To compare the cost-effectiveness of chloroquine (Cq), amodiaquine (Aq), and pyrimethamine-sulfadoxine (PS) for treating malaria.
- To identify the most effective and economical treatment strategy considering drug resistance levels.
Main Methods:
- A decision-analysis model was employed to compare Cq, Aq, and PS.
- Variables included infection probability, drug compliance, side effects, resistance levels, and case-fatality rates.
- Effectiveness measures were parasitologically confirmed cures and deaths prevented in children (6-59 months).
Main Results:
- For 100,000 febrile episodes, costs were US$1812 (Cq), US$2622 (PS), and US$3044 (Aq).
- Drug resistance prevalence, particularly high-level CRPF (RIII), significantly impacted cost-effectiveness.
- With high-level CRPF, PS was more cost-effective (US$0.05/cure, US$1.52/death prevented) than Cq (US$0.47/cure, US$2.29/death prevented).
Conclusions:
- Pyrimethamine-sulfadoxine (PS) is the most cost-effective treatment when RIII-level CRPF prevalence exceeds 14-31%, despite higher initial cost.
- Decision analysis models are valuable tools for malaria control planning and strategy reassessment.
- The study highlights the need for adaptive treatment strategies based on evolving drug resistance patterns.
Abstract:
Because chloroquine (Cq)-resistant Plasmodium falciparum (CRPF) has now spread throughout most of Africa, the efficacy and practicability of other drugs such as amodiaquine (Aq), and pyrimethamine-sulfadoxine (PS), for the treatment of fever needs to be assessed. We used a decision-analysis model to compare the cost and effectiveness of Cq, Aq, and PS. The variables considered were the probability of P. falciparum infection, drug compliance, minor and lethal side effects of the drug, the level of drug resistance in the community, and case-fatality rates associated with treatment. The measures of effectiveness were the number of malaria-related fever episodes cured parasitologically with each treatment and the number of malaria deaths prevented in children 6-59 months old. Cost-effectiveness comparisons were made for cases cured and deaths prevented. For treating 100,000 febrile episodes, Cq, PS, and Aq cost US$1812, US$2622, and US$3044, respectively. Cost of the drug, compliance, and the level of CRPF had the greatest effect on the cost-effectiveness ratio. The prevalence of high-level drug resistance (RIII) was the most important determinant of the cost-effectiveness. In a scenario with high-level CRPF, treatment with Cq costs US$0.47 to cure one patient and US$2.29 to prevent one death compared with US$0.05 and US$1.52 for treatment with PS. When the prevalence of RIII-level CRPF is greater than 14-31% (depending on the level of compliance), the most cost-effective treatment is PS, despite its 45% greater cost. Decision analysis models will be useful for malaria control planners as strategies are reconsidered in the 1990s.