Implementation of field detection devices for antimalarial quality screening in Lao PDR — A cost-effectiveness analysis

Abstract

Substandard and falsified (SF) antimalarials have devastating consequences including increased morbidity, mortality and economic losses. Portable medicine quality screening devices are increasingly available, but whether their use for the detection of SF antimalarials is cost-effective is not known. We evaluated the cost-effectiveness of introducing such devices in post-market surveillance in pharmacies in Laos, conservatively focusing on their outcome in detecting SF artemisinin-based combination therapies (ACTs). We simulated the deployment of six portable screening devices: two handheld near-infrared [MicroPHAZIR RX, NIR-S-G1], two handheld Raman [Progeny, TruScan RM]; one portable mid-infrared [4500a FTIR] spectrometers, and single-use disposable paper analytical devices [PADs]. We considered two scenarios with high and low levels of SF ACTs. Different sampling strategies in which medicine inspectors would test 1, 2, or 3 sample(s) of each brand of ACT were evaluated. Costs of inspection including device procurement, inspector time, reagents, reference testing, and replacement with genuine ACTs were estimated. Outcomes were measured as disability adjusted life years (DALYs) and incremental cost-effectiveness ratios were estimated for each device compared with a baseline of visual inspections alone. In the scenario with high levels of SF ACTs, all devices were cost-effective with a 1-sample strategy. In the scenario of low levels of SF ACTs, only four devices (MicroPHAZIR RX, 4500a FTIR, NIR-S-G1, and PADs) were cost-effective with a 1-sample strategy. In the multi-way comparative analysis, in both scenarios the NIR-S-G1 testing 2 samples was the most cost-effective option. Routine inspection of ACT quality using portable screening devices is likely to be cost-effective in the Laos context. This work should encourage policy-makers or regulators to further investigate investment in portable screening devices to detect SF medicines and reduce their associated undesired health and economic burdens.

Author summary

Distribution of poor quality medicines are an increasing global concern, especially in low- and middle-income countries (LMICs) where the effectiveness of antimicrobials can be a matter of life-or-death for patients with malaria and other potentially fatal infectious diseases. Substandard and falsified antimalarial drugs, including artemisinin-based combination therapies are widely distributed across LMICs. This endangers patients and in the longer term threatens malaria control and elimination campaigns by promoting the development of drug resistance. New field detection devices are increasingly available and could enhance the inspection process with prompt and actionable, real-time results. We conducted a cost-effectiveness analysis of the implementation of six portable devices for medicine quality screening during pharmacy post-market surveillances in Laos. This analysis conservatively focused only on the benefits of these devices in detecting substandard and falsified artemisinin-based combination therapies (ACTs), measured in terms of health outcomes for malaria patients obtaining treatment from pharmacies. Our findings suggest that using these portable devices for routine surveillance of ACT quality is likely to be cost-effective. Policy-makers and regulators might therefore consider investment in these field detection devices to minimise undesired health and economic burdens associated with substandard and falsified medicines.