# Cost comparison of school-based mass drug administration of albendazole and ivermectin versus albendazole alone for soil-transmitted helminth control in Uganda

## TL;DR

This study compares the costs of giving children albendazole and ivermectin together versus albendazole alone in Uganda, finding the combination is more expensive but may be more effective.

## Contribution

The study provides a detailed cost comparison of co-administering albendazole and ivermectin versus albendazole alone for helminth control in a school-based setting.

## Key findings

- Co-administration of albendazole and ivermectin was significantly more costly than albendazole alone.
- Additional costs were driven by training, drug distribution, and informed consent processes.
- Community engagement and health worker involvement were crucial for treatment coverage.

## Abstract

The co-administration of albendazole and ivermectin (ALB-IVM) is recommended for the treatment of soil-transmitted helminth (STH) infections, especially where the prevalence of Trichuris trichiura is high. Before large-scale implementation can be considered, feasibility, acceptability and required resources and investments for the mass drug administration (MDA) of ALB-IVM compared with albendazole (ALB) alone should be assessed. This study, conducted in two districts in south-western Uganda, aimed to assess and compare the costs of school-based MDA with ALB-IVM (MDA-ALB-IVM) versus the routinely used ALB alone (MDA-ALB) on a small scale (targeting around 2,500 children per treatment arm per district). We applied a micro-costing (mixed top-down and bottom-up) approach to assess the financial costs from a health system perspective, as well as the opportunity costs of donated ALB. The total (financial and opportunity) costs of MDA-ALB-IVM were higher than those of MDA-ALB ($10,793 for MDA-ALB-IVM versus $4,458 for MDA-ALB in Kabale district and $14,445 versus $5,765 in Kisoro, respectively). The presence of informed consent and assent required for MDA-ALB-IVM (as ALB-IVM is still considered a new therapy for STH infections in Uganda) increased the number of days and resources including personnel requirements for training and drug distribution. Furthermore, adequate community sensitization and the involvement of community health workers (i.e., village health teams in Uganda) and local community leaders appeared to be essential to achieve high treatment coverage. The scenario analysis showed that, in the absence of the informed consent and assent process, the total incremental costs of MDA-ALB-IVM compared with MDA-ALB could decrease by 31%-36% in the two districts. This study identifies key cost drivers and offers insights for the wider implementation of ALB-IVM co-administration.

The combination of albendazole and ivermectin (ALB-IVM) shows higher efficacy against Trichuris trichiura compared with albendazole (ALB) alone. This combination is recommended for the treatment of STH infections, especially where T. trichiura infection is common. ALB is provided as a single fixed dose, while IVM is dosed using a dose pole to approximate height ranges to weight-based dosing ranges. The different dosing procedures may impact training needs and drug distribution procedures. Before the larger-scale distribution of the combination treatment is implemented, it should be investigated what additional resources and investments are required for ALB-IVM co-administration compared with ALB alone. In this study, we assessed the costs of ALB-IVM co-administration versus ALB alone on a small scale (20 schools in south-western Uganda). The findings showed higher costs of ALB-IVM co-administration than ALB alone. The incremental costs were mainly due to additional resources and day(s) required for training and drug distribution. The study also found that good communication with communities and involving community health workers and local leaders might be important to achieve high treatment coverage. In conclusion, this study highlights the key cost factors and provides insights to support wider rollout of ALB-IVM co-administration.