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Review 1: "Cost-effectiveness of Vector Control Strategies for Supplementing Mass Drug Administration for Eliminating Lymphatic Filariasis in India"

Reviewers have highlighted that this is an important study but raised major concerns related to the methods and data section, recommending the inclusion of robustness and sensitivity analysis.

Published onMar 04, 2024
Review 1: "Cost-effectiveness of Vector Control Strategies for Supplementing Mass Drug Administration for Eliminating Lymphatic Filariasis in India"
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key-enterThis Pub is a Review of
Cost-effectiveness of vector control strategies for supplementing mass drug administration for eliminating lymphatic filariasis in India
Cost-effectiveness of vector control strategies for supplementing mass drug administration for eliminating lymphatic filariasis in India

Abstract Background/Methodology Despite progress using mass drug administration (MDA), lymphatic filariasis (LF) remains a major public health issue in India. Vector control (VC) is hypothesized as a potentially useful addition to MDA towards LF elimination. We conducted cost-effectiveness analysis of MDA alone and augmented by VC single (VCS) or integrated VC approaches (VCI). Data came from historical controls and a 3-arm cluster randomized trial of 36 villages at risk of LF transmission in Tamil Nadu, India. The arms were: MDA alone (the standard of care); VCS (MDA plus expanded polystyrene beads for covering the water surface in wells and cesspits to suppress the filariasis vector mosquito Culex quinquefasciatus), and VCI (VCS plus insecticidal pyrethroid impregnated curtains over windows, doors, and eaves). Economic costs in 2010 US$ combined government and community inputs from household to state levels. Outcomes were controlled microfilaria prevalence (MfP) and antigen prevalence (AgP) to conventional elimination targets (MfP<1% and AgP<2%) from 2010 to 2013, and disability adjusted life years (DALYs) averted.Principal Findings The estimated annual economic cost per resident was US$0.53 for MDA alone, US$1.02 for VCS, and US$1.83 for VCI. With MDA offered in all arms, all reduced LF prevalence substantially and significantly from 2010 to 2013. MDA proved highly cost effective at $112 per DALY, a very small (8%) share of India’s then per capita GDP. Progress towards elimination was comparable across all three study arms.Conclusions The well-functioning MDA was effective and very cost-effective for eliminating LF, leaving little scope for further improvement. Supplementary VC demonstrated no statistically significant additional benefit in this trial.Authors’ Summary Lymphatic filariasis (LF) is one of the twenty neglected tropical diseases (NTDs) that affect more than one billion people worldwide. As part of the effort toward global elimination of LF, the Indian State of Tamil Nadu government has implemented mass drug administration (MDA) repeatedly since 1996. Despite their efforts, LF had not yet been eliminated. Although vector control (VC) is proposed to augment regular MDA to help eliminate LF, little is known about the increased impact or costs. Our study compares the costs of MDA alone to the combination of MDA with alternative VC interventions. We calculated both program operating costs and costs to communities. We found MDA to be very cost-effective for eliminating LF. Against low levels of LF endemicity (≤10%), the study had limited ability to detect further improvements and found no significant incremental improvements from VC.

RR:C19 Evidence Scale rating by reviewer:

Not informative. The flaws in the data and methods in this study are sufficiently serious that they do not substantially justify the claims made. It is not possible to say whether the results and conclusions would match that of the hypothetical ideal study. The study should not be considered as evidence by decision-makers.


Review: In this manuscript, the authors indicate that mass drug administration (MDA) against lymphatic filariasis (LF) alone is the most cost-effective strategy. They claim that adding vector control interventions (single or integrated) have no significant impact to control or eradicate LF in India.

While the study is highly relevant to understand the impact of different strategies to control LF, the paper lacks of clarity on the methods used to estimate incremental effect of adding vector control strategies. The results of the regression analysis are contra-intuitive, as one would expect that adding an intervention on top of the already functional MDA will only increase effectiveness overall. This was not the case when estimating the incremental effectiveness for the integrated vector control. The lack of clarity on how the authors came to this conclusion leaves one wondering on the actual reliability of the results, especially when the authors have highlighted the potential cost-effectiveness of adding such interventions (references 22 to 25). Authors should have used this information to run the model or estimate the added benefit of using VC strategies, but this is not the case. 

Additionally results on the cost-effectiveness analysis are not presented as expected, incremental costs and incremental outcomes should be presented in a summary table along with the ICERs and a comparison against a potential threshold value for India. An analysis of uncertainty is not present nor is a scatter plot or cost-effectiveness acceptability curve. The authors have not done enough to convince the reader of the robustness and reliability of the results, hence this paper is not informative in its current form.

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