Browsing by Author "Wilkinson, Thomas"

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    Open Access
    Cost utility and budget impact analysis of bortezomib and lenalidomide for the treatment of relapsed/refractory multiple myeloma in the South African public health sector
    (2021) Matsela, Lineo Marie; Cleary, Susan; Wilkinson, Thomas
    Multiple myeloma (MM) is the second most common haematologic cancer, accounting for approximately 13% of all blood cancer cases worldwide. The global incidence rate increased by 126% from 1990 to 2016. In South Africa, multiple myeloma accounts for approximately 9% of haematological cancers and less than 1% of all cancers. Nevertheless, some studies have reported that the incidence is likely underestimated due to an underdiagnosis of the cancer. Thus, the disease could possibly be an issue of greater concern in South Africa than current statistics indicate. The nature of the MM tumour makes patients prone to resistance of chemotherapy and multiple relapses leading to the development of relapse/refractory multiple myeloma (RRMM). During the relapse/refractory period, the patient is nonresponsive to treatment and/or experiences progressive disease When a patient experiences relapse/refractory MM, their prior, (first line) treatment is readministered if it was clinically efficacious and well-tolerated. Contrarily, a change in regimen is recommended if “an insufficient response, a rapid relapse and poor tolerance” to the first-line treatment is experienced by a patient. Second-line regimens that are recommended due to their proven high clinical efficacy are lenalidomide plus low-dose dexamethasone (LEN/DEX) and bortezomib monotherapy (BORT). The clinical effectiveness of both regimens for second-line treatment of RRMM was reported in the MM009/010 and the APEX studies, respectively, where each regimen was compared against dexamethasone monotherapy. Given this proven clinical effectiveness for RRMM, lenalidomide is under consideration for inclusion in the South African Essential Medicines list. Three treatment strategies for second line RRMM treatment were modelled from a provider's perspective. These strategies were dexamethasone (standard of care), BORT and LEN/DEX. For each strategy we modelled a hypothetical cohort of relapsed/refractory multiple myeloma patients using a three-state Markov model (pre-progression, progression and dead) over a 15-year time horizon. Efficacy data was obtained from the MM009/010 and APEX trials, while utilisation rates were obtained from a European study. Other input data was sourced from local literature. Outcomes were reported in quality adjusted life years (QALYs). Incremental cost effectiveness ratios (ICERs) were calculated for BORT and LEN/DEX and compared to the local cost-effectiveness threshold to determine if the drugs are good value for money for the South African government. The total costs per patient using DEX, BORT and LEN/DEX over 15 years differed significantly resulting in estimates of R8 312.32, R234 995.50 and R1 135 323.37, respectively. The associated health benefits in terms of quality-adjusted life years gained from the treatments were 1.14, 1.49 and 2.29. Hence, for every quality adjusted life year gained from BORT relative to DEX, an additional R654 648.52 would need to be spent. In contrast, when BORT is compared to LEN/DEX, an additional R1 225 542.23 would need to be spent for an additional quality adjusted life year gained from LEN/DEX. Both the BORT and LEN/DEX treatments were not cost-effective relative to the costeffectiveness threshold of R38 500 per DALY gained. Due to the high costs, both BORT and LEN/DEX could potentially have significant economic impacts on the South African public health sector budget. The study suggests that one year of treatment for 337 RRMM patients in South Africa using the BORT and LEN/DEX would increase the budget budget-cost of RRMM treatment by 3136% and 8684%, respectively. Both BORT and LEN/DEX treatments would not be cost-effective strategies for second-line treatment of RRMM in South Africa. The results indicate that the drug prices of lenalidomide and bortezomib hinder the cost-effectiveness of BORT and LEN/DEX. Price reductions could potentially make BORT more cost-effective and allow it to be considered as an option for second-line treatment for RRMM patients.
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    Costing analysis of levofloxacin as antibiotic prophylaxis for pediatric household contacts of multi-drug resistant tuberculosis patients in a South African setting
    (2021) Fortuin, Suereta; Wilkinson, Thomas
    Background The incidence of TB in children under 15 years, accounts for 8% of the global TB burden. In 2018, the World Health Organisation (WHO) estimated that there were approximately 11 000 multi-drug resistant (MDR) TB cases in South Africa. Despite having very clear guidelines on TB treatment programs and management, availability of inexpensive diagnostic tests, curative and preventive therapies, and the widespread use of the BCG vaccines, South Africa continues to have the highest the number of MDR-TB cases per capita. Levofloxacin is used as part of the group of fluoroquinolones in the drug regimen recommended in the treatment of MDR-TB patients. In addition to investigating the clinical impact of levofloxacin as preventative antibiotic therapy, the expected costs of the intervention will be a critical input to determining feasibility and costs effectiveness, which will inform policy and implementation considerations. Methods We performed a cost analysis on using existing data from the Tuberculosis Child Multi-drug-resistant Preventative Therapy (TB-CHAMP) trial, conducted from a TB control program perspective. We used data from 510 childhood household contacts of MDR-TB patients in South Africa that were treated with levofloxacin for 6 months as a preventative therapy for MDR-TB. In our analysis we evaluated the estimated health system cost associated with provision of levofloxacin to childhood contacts of MDRTB patients in South Africa. Results The mean total cost of treating a child household contact, irrespective of their weight band is ZAR 5,289.79. When the cost were analysed by weight categories we found that the cost increased by weight category; ZAR 2,146.78 (under 5 kg), ZAR 4,714.58 (between 5-15.9 kg) and ZAR 6,606.67 (over 16 kg). We performed a comprehensive sensitivity analysis and found that the scheduled clinic visits were the major cost driver. Aside from the scheduled visits we observed that there was an increase in additional health service utilization for children with a weight more than 5kg. Conclusion We envisage that based on our analysis we will be able to inform policy decisions about the management and prevention of childhood household contacts of MDR-TB patients in developing TB themselves.
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    Socioeconomic differentials in child stunting in rural and urban areas in Zambia
    (2019) Mushinge, Douglas; Ataguba, John; Wilkinson, Thomas
    Child stunting remains one of the biggest public health concerns in Zambia and other low and middle-income countries (LMICs). A formidable challenge faced in improving child health outcomes in LMICs includes persistent socioeconomic and residential disparities. Despite achieving an overall decline in the prevalence of child stunting over the past decades, children residing in rural areas and less-privileged households continue to fall behind their peers from urban areas and wealthier households in Zambia and other LMICs. Notably, studies have shown that children residing in rural areas and less privileged households have a higher risk and burden of stunted growth in sub-Saharan Africa (SSA). However, basic rural-urban differentiation in child stunting can potentially conceal wealth differentials that exist within rural and urban areas. Specifically, cross country analyses have revealed that wealth differentials were higher in urban areas compared to rural areas; and higher than the overall urban-rural odds of stunting among children under five years of age. Using data from the 2013/14 Zambia Demographic Health Survey (ZDHS), differences in the relationship between socioeconomic status and child stunting in urban and rural areas of Zambia were assessed in this study. Furthermore, the study examines the effect of socioeconomic status and residence type in predicting child stunting prevalence in Zambia. To achieve these, the thesis used chi-square tests and logistic regression analysis. To the best of my knowledge, this is the first single-country analysis primarily focused on Zambia that has disaggregated the effect of predictors of child stunting by residence type. It is anticipated that the results of this dissertation will broaden the knowledge-base on wealth and residential differentials in child nutritional outcomes in Africa and thereby provide useful information to policymakers and technocrats in Zambia. Overall, the findings indicate that children under five years who reside in urban areas and poorer households have a higher likelihood of becoming stunted compared to their peers in rural and wealthier households. However, the relationship between child stunting and household wealth (SES) differs slightly after segregating by residence type. In both rural and urban areas, there is a consistent inverse relationship between the odds of stunted growth among under-fives and SES. Furthermore, these findings indicate that socioeconomic differentials are wider in rural areas compared to urban areas and much wider than the overall rural-urban odds ratios in Zambia. These findings could possibly be because of socioeconomic inequalities in child stunting that are higher in rural areas than urban areas. However, there is a need for further research to examine the causes of differentials in child stunting that may exist in rural and urban locations of Zambia.