Costs and Outcomes of Integrated Human African Trypanosomiasis Surveillance System Using Rapid Diagnostic Tests, Democratic Republic of the Congo

Abstract

We integrated sleeping sickness case detection into the primary healthcare system in 2 health districts in the Democratic Republic of the Congo. We replaced a less field-friendly serologic test with a rapid diagnostic test, which was followed up by human African trypanosomiasis microscopic testing, and used a mixed costing methodology to estimate costs from a healthcare provider perspective. We screened a total of 18,225 persons and identified 27 new cases. Average financial cost (i.e., actual expenditures) was US $6.70/person screened and $4,464/case diagnosed and treated. Average economic cost (i.e., value of resources foregone that could have been used for other purposes) was $9.40/person screened and $6,138/case diagnosed and treated. Our study shows that integrating sleeping sickness surveillance into the primary healthcare system is feasible and highlights challenges in completing the diagnostic referral process and developing a context-adapted diagnostic algorithm for the large-scale implementation of this strategy in a sustainable and low-cost manner.

Keywords: Democratic Republic of the Congo; costs; diagnosis; human African trypanosomiasis; integration; parasites; primary health services; sleeping sickness; surveillance.

Figure 1

Health facilities performing HAT surveillance and the average human African trypanosomiasis incidence (cases/10,000 population), Democratic Republic of the Congo, 2013–2015. Inset shows location of the country in Africa. Map generated by using QGIS 3.10.1 (4). HAT, human African trypanosomiasis; RDT, rapid diagnostic test.

Figure 2

Diagnostic algorithm applied after a negative malaria test, persistent fever after malaria treatment, or symptoms suggestive of human African trypanosomiasis, Democratic Republic of the Congo. LGP, Lymph gland puncture; LP, lumbar puncture; mAECT, mini anion exchange centrifugation test; NEXT, nifurtimox/eflornithine combination therapy; RDT, rapid diagnostic test.

Figure 3

Cost per person screened and per human African trypanosomiasis case diagnosed and treated, Democratic Republic of the Congo.

Figure 4

Sensitivity analysis on main cost drivers for HAT diagnosis and treatment, Democratic Republic of the Congo. HAT, human African trypanosomiasis.

Figure 5

Illustration of potential loss in effectiveness in passive screening for HAT integrated into the primary healthcare system using an adaptation of Piot model for tuberculosis (36), Democratic Republic of the Congo. HAT, human African trypanosomiasis; RDT, rapid diagnostic test.