Costs and outcomes of active and passive case detection for visceral leishmaniasis (Kala-Azar) to inform elimination strategies in Bihar, India

Abstract

Background Effective case identification strategies are fundamental to capturing the remaining visceral leishmaniasis (VL) cases in India. To inform government strategies to reach and sustain elimination benchmarks, this study presents costs of active- and passive- case detection (ACD and PCD) strategies used in India’s most VL-endemic state, Bihar, with a focus on programme outcomes stratified by district-level incidence. Methods Expenditure analysis was complemented by onsite micro-costing to compare the cost of PCD in hospitals alongside index case-based ACD and a combination of blanket (house-to-house) and camp ACD from January to December 2018. From the provider’s perspective, a cost analysis evaluated the overall programme cost of each activity, the cost per case detected, and the cost of scaling up ACD. Results During 2018, index case-based ACD, blanket and camp ACD, and PCD reported 1,497, 131, and 1,983 VL-positive cases at a unit cost of $522.81, $4,186.81, and $246.79, respectively. In high endemic districts, more VL cases were identified through PCD while in meso- and low-endemic districts more cases were identified through ACD. The cost of scaling up ACD to identify 3,000 additional cases ranged from $1.6–4 million, depending on the extent to which blanket and camp ACD was relied upon. Conclusion Cost per VL test conducted (rather than VL-positive case identified) may be a better metric estimating unit costs to scale up ACD in Bihar. As more VL cases were identified in meso-and low-endemic districts through ACD than PCD, health authorities in India should consider bolstering ACD in these areas. Blanket and camp ACD identified fewer cases at a higher unit cost than index case-based ACD. However, the value of detecting additional VL cases early outweighs long-term costs for reaching and sustaining VL elimination benchmarks in India.

Using Passive Surveillance to Maintain Elimination as a Public Health Problem for Neglected Tropical Diseases: A Model-Based Exploration

“…Reactive policies, which would increase detection and treatment, would strengthen the use of passive surveillance but may be challenging if passive surveillance systems are not able to detect ongoing transmission at low levels [ 13 ]. For example, for visceral leishmaniasis prevalence has been shown to have an effect on the effectiveness of passive and active case detection [ 14 ]. These types of dynamics could be due to both program effects (how good healthcare is at diagnosing when a case turns up) and population effects (how good people are at going to healthcare depending on awareness and perception of risk).…”

Entomological, parasitological and molecular investigations in a new focus of cutaneous leishmaniasis in Youssoufia region, Morocco

“…In the same way in high endemic districts, more cases were identified by passive case‐detection (PCD), despite routine surveillance does not usually permit accurate assessments of any changes in the incidence of leishmaniasis (Ready, 2014). While in meso‐ and low‐endemic districts, more cases were identified by ACD; however, the cost of extending the ACD was expensive (Dial et al., 2021). These ACD strategies not only reduce the time to diagnosis (Rubiano et al., 2021) and thus the risk of transmission (Dubey et al., 2021) but also contribute to regional reduction of leishmaniasis (Das et al., 2014).…”

Mutual Role of Patients and the Healthcare System in the Control of Cutaneous Leishmaniasis

“…In a study, active case detection in VL cases significantly reduced the time from the onset of fever to diagnosis [132]. Studies revealed that the cost of early detection of further VL and CL cases is lower than outweighs the long-term costs for achieving VL and CL elimination benchmarks [133,134]. Also, active case detection is cost-effective in regions where the incidence rate is high [133].…”

“…Studies revealed that the cost of early detection of further VL and CL cases is lower than outweighs the long-term costs for achieving VL and CL elimination benchmarks [133,134]. Also, active case detection is cost-effective in regions where the incidence rate is high [133]. Furthermore, active case detection and early treatment of ACL cases could be effective approaches to controlling the disease, especially in times of epidemics such as in the earthquake in Bam, Iran [135].…”