Economic studies of malaria in pregnancy interventions

Project Coordinator:    Prof Kara Hanson (LSHTM, UK)

Co-investigators:          Silke Fernandes (LSHTM, UK), Dr Elisa Sicuri (IS Global, Spain)

The objectives of the economic studies were to:

1. Describe the economic burden of MiP in Africa, Latin America and India.
2. Determine the cost effectiveness of integrated approaches to prevention of MiP.

Household costs were estimated through exit interviews with pregnant women attending antenatal clinics.

Intervention costs were estimated through observational studies collected alongside the trails, using national salary scales, drug and commodity costs from international procurement databases and local costs.

Health systems costs were estimated through bottom-up costing studies conducted in antenatal clinics, obstetric and paediatric wards in hospitals near the study sites

Cost -effectiveness studies were estimated with incremental cost-effectiveness ratios using decision tree models. Probabilistic sensitivity analysis and simulations with hypothetical cohorts of pregnant women were carried out and disability-adjusted life years (DALYS for low birth weight, severe or moderate anaemia, clinical malaria, stillbirth and neonatal death were calculated).

Cost-effectiveness of 2 vs 3 or more doses of intermittent preventive treatment with SP (IPTp-SP):  The findings of an analysis from a societal perspective of the 2013 meta-analysis of seven studies in sub-Saharan Africa, strongly supported the WHO policy update in 2012 which recommended monthly IPTp-SP of 3 or more doses from the second trimester onwards.

Cost-effectiveness of MQ for IPTp in HIV-negative and HIV-positive pregnant women:  Results showed that addition of IPTp with an effective antimalarial to CTXp was cost-effective in HIV-positive women. Regardless of HIV status, prevention of malaria in pregnancy with a highly efficacious, well tolerated antimalarial would be cost-effective despite its high price. These results were presented at the WHO’s ERG.

Cost-effectiveness of intermittent screening and treatment with artemether-lumefantrine (IST-AL) vs. IPTp-SP in West Africa:   IST-AL was more expensive and no more effective than IPTp-SP, and therefore not cost-effective at current levels of SP efficacy. The cost-effectiveness of ISTp-AL increases as the efficacy of IPTp-SP decreases. These results reinforced the conclusion of the July 2015 ERG meeting that it would not be advisable to change to IST under present levels of SP efficacy.

Estimates of out of pocket expenditures in Brazil, Colombia, India and Tanzania: All estimates of cost associated with the treatment and prevention of MiP were higher than expected. With a total medium cost for one episode ranging from US$ 459.58 in India where most cases were due to P. vivax and were hospitalized to Tanzania, where MIP is due to P. falciparum, median direct outpatient costs were US$ 3.06 (IQR 4.44) and median inpatient costs were US$ 21.36 (IQR 17.82). In Tanzania, a significant contribution to total cost was due to anaemia as a second diagnosis.