Diagnostic Accuracy and Cost-Effectiveness of Alternative Methods for Detection of Soil-Transmitted Helminths in a Post-Treatment Setting in Western Kenya

Objectives: This study evaluates the diagnostic accuracy and cost-effectiveness of the Kato-Katz and Mini-FLOTAC methods for detection of soil-transmitted helminths (STH) in a post-treatment setting in western Kenya. A cost analysis also explores the cost implications of collecting samples during school surveys when compared to household surveys. Methods: Stool samples were collected from children (n = 652) attending 18 schools in Bungoma County and diagnosed by the Kato-Katz and Mini-FLOTAC coprological methods. Sensitivity and additional diagnostic performance measures were analyzed using Bayesian latent class modeling. Financial and economic costs were calculated for all survey and diagnostic activities, and cost per child tested, cost per case detected and cost per STH infection correctly classified were estimated. A sensitivity analysis was conducted to assess the impact of various survey parameters on cost estimates. Results: Both diagnostic methods exhibited comparable sensitivity for detection of any STH species over single and consecutive day sampling: 52.0% for single day Kato-Katz; 49.1% for single-day Mini-FLOTAC; 76.9% for consecutive day Kato-Katz; and 74.1% for consecutive day Mini-FLOTAC. Diagnostic performance did not differ significantly between methods for the different STH species. Use of Kato-Katz with school-based sampling was the lowest cost scenario for cost per child tested ($10.14) and cost per case correctly classified ($12.84). Cost per case detected was lowest for Kato-Katz used in community-based sampling ($128.24). Sensitivity analysis revealed the cost of case detection for any STH decreased non-linearly as prevalence rates increased and was influenced by the number of samples collected. Conclusions: The Kato-Katz method was comparable in diagnostic sensitivity to the Mini-FLOTAC method, but afforded greater cost-effectiveness. Future work is required to evaluate the cost-effectiveness of STH surveillance in different settings. Author Summary: Accurate methods of diagnosis and optimal strategies to sample the population are essential for the reliable mapping and surveillance of infectious diseases. The current standard for detection of soil-transmitted helminths (STH) entails use of the Kato-Katz diagnostic method. Alternative diagnostic methods, such as flotation techniques like the Mini-FLOTAC, have been developed with hopes of achieving greater sensitivity and ease of use. Here, we evaluate the diagnostic accuracy of the Kato-Katz method and the Mini-FLOTAC method for detecting STH infection. We use Bayesian latent class modeling to calculate the diagnostic accuracy in the absence of a gold-standard method for STH detection. Stool samples were collected from school-age children using school-based and community-based sampling. We present cost estimates for use of the Kato-Katz and Mini-FLOTAC diagnostic methods in combination with both sampling methods, providing cost data for the various survey scenarios. Sensitivity was comparable between the Kato-Katz and Mini-FLOTAC methods for detection of any STH species over a single day (Kato Katz: 52.0%, Mini-FLOTAC: 49.1%) and consecutive days (Kato-Katz: 76.9%, Mini-FLOTAC: 74.1%). Costs were lowest in scenarios using the Kato-Katz method; cost per child tested and cost per case correctly classified for school-based sampling with the Kato-Katz diagnostic were $10.14 and $12.84 respectively. The lowest cost per case detected was $128.24 with community-based sampling and use of Kato-Katz. Further work is required on the cost-effectiveness of diagnostic and sampling methods for STH surveys and surveillance of other neglected tropical diseases (NTDs) in various settings. To this end, we provide the model code used in the diagnostic analysis and a costing template for STH surveys.