Modelling the cost of engage & treat and test & treat strategies towards the elimination of lymphatic filariasis in Ghana

Background: Despite several years of LF-MDA implementation, Ghana still has some districts with mf prevalence >1%, partly due to poor treatment coverage levels resulting from non-participation in MDA. To address the challenges, we implemented Engage & Treat (E&T) and Test & Treat (T&T) strategies for individuals who miss or refuse MDA respectively, in a hotspot district, enabling us to reach many of those who seldom, or never, take part in MDA. This financial cost study was undertaken to analyse data on the LF-MDA, E&T and T&T implementation in 2021 and the financial cost to inform the rollout of the E&T and T&T as mop-up strategies in future LF-MDAs. Methods: This costing study analysed cost data from the 2021 LF-MDA implementation activities carried out by the Neglected Tropical Diseases (NTD) programme of the Ghana Health Service and the SENTINEL study, carried out in Ahanta West district for the two interventions (i.e., E&T and T&T). The 2021 Ghana Population and Housing Census data was used to estimate the LF-MDA-eligible population. The financial cost per person treated was estimated and these costs were applied to the projected population to obtain the financial cost for subsequent years. Results: Implementing MDA mop-up strategies either through the E&T or T&T to improve coverage comes at an additional cost to the elimination goals. For example, in 2024 the projected cost per person treated by the routine LF-MDA is estimated at US$0.83. The cost using the integrated LF-MDA and the E&T, T&T led by the NTD programme or T&T integrated into the health system was estimated at US$1.62, US$2.88, and US$2.33, respectively, for the same year. Despite the increased cost, the proposed combined LF-MDA and mop-up strategies will have a higher estimated population treated for 2024 (i.e., 1,392,211) compared to the routine LF-MDA approach (i.e., 988,470) for the same year. Conclusion: Combining LF-MDA with E&T/T&T mop-up strategies, despite their high costs, may provide NTD Programmes with the options of improving treatment coverage and reaching the LF elimination target sooner, given that the routine LF-MDA alone approach has been implemented for many years with some districts yet to reach the elimination targets. Author summary: In Ghana, despite many years of efforts to eliminate lymphatic filariasis (LF) through mass drug administration (MDA), some districts still have a prevalence of infection above the threshold required to eliminate the disease as a public health problem. This is partly because not everyone in these districts is participating in the MDA programme. To tackle this challenge, new strategies called Engage & Treat (E&T) and Test & Treat (T&T) were implemented in a hotspot district. These strategies focus on reaching individuals who either miss or refuse MDA, ensuring that even those who rarely or never participate are covered. A financial cost study was undertaken to analyze the data from LF-MDA, E&T, and T&T implementations in 2021 to understand the financial implications for future LF-MDA efforts. The study looked at the cost data from LF-MDA activities conducted by the Neglected Tropical Diseases (NTD) programme of the Ghana Health Service and the SENTINEL study in the Ahanta West district for the E&T and T&T interventions. Population data from the 2021 Ghana Population and Housing Census were used to estimate the LF-MDA-eligible population in the country. The study found that implementing these strategies, either through E&T or T&T, to improve coverage comes with an additional cost to the LF elimination goals. For example, in 2024, the projected cost per person treated by the routine LF-MDA alone is estimated at US$0.83. However, when combining LF-MDA with E&T or T&T, the costs increase to US$1.62, US$2.88, respectively, for the same year. Despite the higher costs, the combined LF-MDA and mop-up strategies are estimated to treat a larger population in 2024 (1,392,211) compared to the routine LF-MDA approach (988,470) for the same year. In summary, although the combined LF-MDA and mop-up strategies have higher costs, they may offer NTD Programmes the option to improve treatment coverage and achieve the LF elimination target sooner. This is particularly important as the routine LF-MDA alone approach has been in place for many years, with some districts still facing challenges in reaching elimination targets.