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. 2019 Apr;17(2):213-230.
doi: 10.1007/s40258-018-0449-8.

Cost Effectiveness of New Diagnostic Tools for Cutaneous Leishmaniasis in Afghanistan

Céline Aerts  1 , Martijn Vink  2 , Sayed Jalal Pashtoon  3 , Sami Nahzat  4 , Albert Picado  5 , Israel Cruz  5 , Elisa Sicuri  6   7
Affiliations

Cost Effectiveness of New Diagnostic Tools for Cutaneous Leishmaniasis in Afghanistan

Céline Aerts et al. Appl Health Econ Health Policy. 2019 Apr.

Abstract

Background and objectives: Cutaneous leishmaniasis is responsible for chronic and disfiguring skin lesions resulting in morbidity and social stigma. The gold standard to diagnose cutaneous leishmaniasis is microscopy but has a variable sensitivity and requires trained personnel. Using four scenarios, the objective of this study is to compare the cost effectiveness of microscopy with two new tools: Loopamp™ Leishmania Detection Kit (LAMP) and CL Detect™ Rapid Test (RDT).

Methods: Data related to the cost and accuracy of these tools were collected at the clinic of the National Malaria and Leishmaniasis Control Program in Kabul, Afghanistan. The effectiveness estimates were measured based on the tools' performance but also indirectly, using the disability-adjusted life years. A decision tree was designed in TreeAge Healthcare Pro 2016, combined with a Markov model representing the natural history of cutaneous leishmaniasis. In addition to a deterministic analysis, univariate sensitivity and probabilistic analyses were performed to test the robustness of the results.

Results: If the tools are compared at the National Malaria and Leishmaniasis Control Program level in a period of low incidence, microscopy remains the preferred option. LAMP becomes more appropriate during cutaneous leishmaniasis seasons or outbreaks when its capacity to process several tests (e.g. up to 48) at a time can be maximised. RDT has a cost similar to microscopy when used at the reference clinic but as it is relatively easy to use, it could be implemented at the peripheral level, which would become cheaper than employing microscopy at the reference clinic. Moreover, combining RDT with microscopy or LAMP at the reference clinic for the negative suspects is economically more interesting than directly performing LAMP or microscopy respectively on all cutaneous leishmaniasis suspects at the reference clinic.

Conclusions: When taking advantage of their respective strengths, LAMP and RDT can prove to be cost-effective alternatives to using microscopy alone at the reference clinic.

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Conflict of interest statement

Conflict of Interest

Céline Aerts, Martijn Vink, Sayed Jalal Pashtoon, Sami Nahzat, Albert Picado, Israel Cruz and Elisa Sicuri have no conflicts of interest that are directly relevant to the contents of this article.

Ethics Approval

The study was carried out in accordance with the Helsinki Declaration, and approved by the Institutional Review Board of the National Public Health Institute, Ministry of Public Health, Islamic Republic of Afghanistan (Approval No. 361549).

Consent to Participate

The participants provided written informed consent in a one-on-one session with a member of the study. For illiterate individuals, the informed consent process was conducted in the presence of an impartial witness and for minors, the consent from a parent or guardian had to be obtained to be enrolled in the study.

Data Availability

The datasets generated during and/or analysed during the current study are available in the figshare repository at https://doi.org/10.6084/m9.figshare.6949043.

Figures

Fig. 1
Fig. 1
Decision tree: comparative strategies. CL cutaneous leishmaniasis, LAMP Loopamp™ Leishmania Detection Kit, RDT CL Detect™ Rapid Test
Fig. 2
Fig. 2
Natural history of Leishmania tropica
Fig. 3
Fig. 3
Cost-effectiveness graph with willingness-to-pay (WTP) line. DALYs disability-adjusted life-years, LAMP Loopamp™ Leishmania Detection Kit, RDT CL Detect™ Rapid Test
Fig. 3
Fig. 3
Cost-effectiveness graph with willingness-to-pay (WTP) line. DALYs disability-adjusted life-years, LAMP Loopamp™ Leishmania Detection Kit, RDT CL Detect™ Rapid Test
Fig. 4
Fig. 4
Tornado diagram. Parameter categories are grouped by color: dark blue represents costs borne by the health system; light blue represents costs borne by the suspects/patients with cutaneous leishmaniasis (CL); red represents transition rates; and green represents patient/clinician behaviours. The values in the parentheses stand for the lower and higher range over which the parameter was varied. The vertical line represents the expected value of the microscopy cost. A segmented bar indicates a change in the cost threshold: CL Detect™ Rapid Test becomes cheaper than microscopy. CLR cutaneous leishmaniasis recidivans, EV, Prob probability
Fig. 5
Fig. 5
Cost-effectiveness plane. The circle represents the 95% ellipse (the 95% credible interval); the willingness-to-pay (WTP) line represents the WTP threshold that is equal to the one time gross domestic product per capita. DALYs disability-adjusted life-years, LAMP Loopamp™ Leishmania Detection Kit, RDT CL Detect™ Rapid Test
Fig. 5
Fig. 5
Cost-effectiveness plane. The circle represents the 95% ellipse (the 95% credible interval); the willingness-to-pay (WTP) line represents the WTP threshold that is equal to the one time gross domestic product per capita. DALYs disability-adjusted life-years, LAMP Loopamp™ Leishmania Detection Kit, RDT CL Detect™ Rapid Test
Fig. 6
Fig. 6
Cost-effectiveness acceptability curves. The y-axis represents the probability of the tools being cost effective while the x-axis represents different willingness-to-pay values. LAMP Loopamp™ Leishmania Detection Kit, RDT CL Detect™ Rapid Test
Fig. 6
Fig. 6
Cost-effectiveness acceptability curves. The y-axis represents the probability of the tools being cost effective while the x-axis represents different willingness-to-pay values. LAMP Loopamp™ Leishmania Detection Kit, RDT CL Detect™ Rapid Test
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