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Azithromycin proving cost-effective mass trachoma control in Nepal
Though no more effective than targeted treatment, mass screening and treatment of children is cheaper.
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Mass treatment of children is more cost-effective than targeted household treatment, and at least as effective in reducing the incidence of trachoma, according to study results published recently in the Bulletin of the World Health Organization.
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The study was conducted in the western most part of Nepal by a team from the F.I. Proctor Foundation headed by Thomas M. Leitman, MD, working closely with local doctors at the Geta Eye Hospital in Dhangadi, Helen Keller International and the Centers for Disease Control and Prevention. Some of the data collected in Nepal over a period of 4 years was given to Kevin D. Frick, MD, a health economist at Johns Hopkins University, for analysis.
“The incidence of trachoma in the region we studied hovers around 15%, or what would be referred to as meso-endemic. We’re not talking about some areas of Africa where trachoma is hyper-endemic, affecting 50% of the population or more,” said Dr. Frick.
The World Health Organization (WHO) generally recommends mass treatment where a disease is hyper-endemic, but in meso-endemic areas, the guidelines are less clear.
“Where the incidence of the disease is only 2% or 3%, then obviously targeted treatment is more cost-advantageous. This is the first example of a cost-effectiveness study conducted in a meso-endemic area,” Dr. Frick said.
Study design
Seventeen individual villages comprising approximately 1,000 to 2,000 persons each, more than 30% of them children between the ages of 1 and 10, were randomly assigned to one of two treatment groups. In the first group, all children were screened and treated with a single, weight-adjusted dose of Zithromax (azithromycin, Pfizer). In the second group, children with active infection were identified using a simple clinical exam (five follicles seen on an inverted eyelid is considered active trachoma), then treated along with all members of their households.
“There is an issue of retransmission within families, but active infection typically decreases with age. Therefore, mass treatment of children alone may be sufficient,” Dr. Frick said.
Costs included personnel time required for treatment, transportation for personnel to and from the villages, lost-opportunity costs for study subjects while waiting for treatment and the cost of azithromycin. Research costs were excluded from this analysis.
Prevalence of trachomatous infection was determined before and after treatment, with effectiveness measured as the percentage point change in the prevalence of trachoma in children aged 1 to 10 between baseline and the 6-month follow-up.
No more effective, but cheaper
No significant differences were found regarding the prevalence of trachoma at follow-up between the two groups.
“This doesn’t completely rule out targeting as a strategy for disease control. A simple clinical exam without a lab test for the infectious agent is neither 100% specific nor 100% sensitive in trachoma, so in this case, it is hard to know exactly who to treat with a brief clinical exam,” Dr. Frick said.
The Proctor Foundation’s Dr. Leitman, an assistant professor of ophthalmology at the University of California, San Francisco, added, “In a meso-endemic community, the targeted approach probably misses active infection 30% of the time — cases of infection that are subclinical, where no follicles are visible. On the other hand, the mass approach misses infection in children over 10 years of age. This is less of a problem, though, because the reservoir is in children. If you can eliminate infection in children, it will disappear in the rest of the community.”
“Targeted treatment is less cost-effective because you need a higher level of personnel to do the screening and they need to return for a second trip to treat the remainder of the household,” Dr. Frick said. Also, a greater amount of azithromycin was needed in the targeted strategy, primarily because dosing is weight-dependent and household treatments included adults.
For Your Information:Reference:
- Thomas M. Lietman, MD, can be reached at the F.I. Proctor Foundation, 95 Kirkham St., San Francisco, CA 94122 U.S.A.; +(1) 415-502-2662; fax: +(1) 415-476-0527; e-mail: tml@itsa.ucsf.edu.
- Kevin Frick, PhD, can be reached at Bloomberg School of Public Health, 624 N. Broadway, Room 606, Baltimore MD 21205 U.S.A.; +(1) 410-614-4018; fax: +(1) 410-955-0470; e-mail: kfrick@jhsph.edu.
- Frick KD, Lietman TM. Cost-effectiveness of trachoma control measures: comparing targeted household treatment and mass treatment of children. Bulletin of the World Health Organization. 2001;79:201-207.