Leprosy post-exposure prophylaxis in the Indian health system: A cost-effectiveness analysis

Abstract

India has the highest burden of leprosy in the world. Following a recent WHO guideline, the Indian National Leprosy Programme is introducing post-exposure prophylaxis with singledose rifampicin (SDR-PEP) in all high-endemic districts of the country. The aim of this study is to estimate the long-term cost-effectiveness of SDR-PEP in different leprosy disability burden situations. We used a stochastic individual-based model (SIMCOLEP) to simulate the leprosy new case detection rate trend and the impact of implementing contact screening and SDR-PEP from 2016 to 2040 (25 years) in the Union Territory of Dadra Nagar Haveli (DNH) in India. Effects of the intervention were expressed as disability adjusted life years (DALY) averted under three assumption of disability prevention: 1) all grade 1 disability (G1D) cases prevented; 2) G1D cases prevented in PB cases only; 3) no disability prevented. Costs were US$ 2.9 per contact. Costs and effects were discounted at 3%.

<p>The State of Affairs in Post-Exposure Leprosy Prevention: A Descriptive Meta-Analysis on Immuno- and Chemo-Prophylaxis</p>

“…It is also estimated to be cost-effective when assessing SDR-PEP in the Indian health system (US$ 2,873 per new leprosy case averted). 116 Demonstrating the operational feasibility of integrating SDR-PEP into leprosy programs on such a large scale in multiple settings has contributed to WHO recommending SDR-PEP in its Guidelines for the Diagnosis, Treatment and Prevention of Leprosy. 52 As part of the LPEP program, two specific approaches for implementing SDR-PEP were piloted.…”

“…One was a blanket approach in Lingat village on Selaru Island, a remote highendemic village in Indonesia. 116 The blanket approach involved total population screening in 2016 (n = 2065). During two visits in consecutive years, 1,671 inhabitants were screened (88%), and 1,499 (79%) received SDR-PEP.…”

“…138 Though, studies have demonstrated that both contact examination and SDR-PEP implementation are cost-effective. 97,116,141 Rodrigues, Lockwood, Krishnamurthy and Penna also argued that contact screening and SDR-PEP administration raise ethical problems because the disclosure of the index-patients' diagnosis to their contacts is required. 138,139 However, the LPEP program results in Brazil illustrated that it is possible to distribute SDR-PEP without disclosing the identity of the index case by solely saying: "There is leprosy in your area, and that is why we offer people preventive treatment against leprosy" (Ignotti, unpublished report).…”

“…146 In very high-endemic hotspot or cluster areas, a total population screening and SDR-PEP administration may be the best approach. 101,116 However, when screening entire populations is neither feasible nor affordable, focal mass drug administration (fMDA) may be a reasonable alternative. 152 The fMDA approach would target the population who are not included in a contact-based PEP approach and would be implemented alongside contact-based PEP.…”

“…Rifampicin is relatively cheap, and its cost-effectiveness was assessed to be good in the COLEP study, and also in India, based on the SIMCOLEP model and the LPEP program. 97,116 Through the Stop TB Partnership/Global Drug Facility, 100 dosages of 150 mg rifampicin cost US$ 6.33, and 100 dosages of 300 mg cost around US$ 10. 154 But SDR-PEP still requires an initial investment from national leprosy control programs in often resource-poor settings, especially when SDR-PEP administration is-as recommended-combined with screening and active case-finding activities.…”