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March 13, 2003

Study Identifies Best Way to Fight Blinding Disease

A researcher at the Johns Hopkins School of Public Health and his colleagues have pinpointed a cost-effective way to battle trachoma -- a childhood eye infection -- common in some developing nations that can lead to scarring of the upper eyelid, in-turned eyelashes, corneal damage, and eventually blindness in adults. The study will help public health authorities in cash-strapped developing countries who depend on hard scientific data to guide them to the most effective and economical treatment strategies. The report appears in the March 2001 issue of the Bulletin of the World Health Organization.

Trachoma can be easily treated with a single dose of an expensive antibiotic or with a six-week course of a less expensive antibiotic. This study looked at the use of the more expensive single-dose antibiotic asking, "What is the best way to administer the drug?" That is, should the antibiotic be given en masse to the entire population susceptible to trachoma (all children ages one to ten years), or should it be narrowly targeted only to those children with active trachoma and their households?

The results of the study showed that the mass distribution method took less time, both for the public health workers and the villagers who received the antibiotic, and used less drug than did the targeted treatment.

"At first glance," said Kevin Frick, PhD, assistant professor, Health Policy and Management, Johns Hopkins School of Public Health, "targeted treatments are intuitively appealing because one expects that the resources used, including antibiotics, will be directed just to those persons most in need and to those around them. We found, however, that targeted household treatment for trachoma was actually less cost-effective than simply treating all children in a village."

The investigators carried out antibiotic interventions in the most westerly part of Nepal, in villages where active trachoma was found to occur in over 15 percent of children. Individual villages were randomly allocated to receive either mass antibiotic treatment (all children ages one to ten years) or targeted treatment (children with active trachoma were first identified and then they and their family members were treated).

The targeted household treatment was no more effective in reducing trachoma, took more time away from both villagers and public health workers, and used slightly more of all resources, according to the study. The results indicated that mass treatment of children should remain the treatment of choice until other methods of distributing targeted treatment are devised and tested.

In the past, cost-effectiveness studies of trachoma control have analyzed only the government's costs; the present study, however, also took into consideration the costs to study subjects themselves and to society as a whole. Villagers' costs, for instance, might include any monetary payments they had to make, as well as the value of time they spent obtaining treatment for their children.

The authors said studying a treatment program's costs and cost-effectiveness from the government's perspective and from the targeted population and the society as a whole is important. "With sufficient planning," said Dr. Frick, "analyses of these extra perspectives require relatively few additional resources for data collection, and their consistent incorporation into future research is important for moving the analysis of the trachoma program forward." This analysis was the first to use a new framework -- developed by Dr. Frick and a colleague at the Johns Hopkins School of Medicine, and spelled out in the March 2001 issue of Ophthalmic Epidemiology -- for conducting this type of cost-effectiveness study. In that article, the authors describe the kinds of data that must be collected to perform similar studies; the types of costs researchers should consider measuring; and the calculations they should use to arrive at the cost-effectiveness ratios that appear in their study.

Support for this study was provided by the Edna McConnell Clark Foundation, Helen Keller International, and the International Trachoma Initiative.

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