Cost-effectiveness of end-game strategies against sleeping sickness across the Democratic Republic of Congo

Gambiense human African trypanosomiasis (gHAT) is marked for elimination of transmission (EoT) by 2030. We examined the cost-effectiveness (CE) of EoT in the Democratic Republic of Congo, which has the highest global gHAT burden. In 166 health zones (HZs), we modelled the transmission dynamics, health outcomes, and economic costs of six strategies during 2024-40, including the cessation of activities after case reporting reduces to zero. Uncertainty in CE was assessed within the net monetary framework, presented as the optimal strategies at a range of willingness-to-pay (WTP) values, denominated in costs per disability-adjusted life-year averted. Status quo strategies, CE strategies (WTP=$500), and strategies with a high probability of EoT by 2030 are predicted to yield EoT by 2030 in 117 HZs, 130 HZs, and 138 HZs respectively, at a cost by 2040 of \$159M (82M--266M), $175M ($98M-$285M), $206M ($114M-$339M). A more lenient timeline of EoT by 2040 could lead to EoT in 153 HZs at a cost of $189M ($105M-$311M), leaving 13 HZs shy of the goal. Investing in EoT by 2030 is predicted to reduce gHAT deaths from 34,770 (14,113-71,118) with status quo strategies to 8,214 (3,284-18,507). ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement This work was supported by the Bill and Melinda Gates Foundation (www.gatesfoundation.org) through the Human African Trypanosomiasis Modelling and Economic Predictions for Policy (HAT MEPP) project \[INV-005121\] (MA, SAS, CH, REC, PEB, EHC, KSR, and FT), and through the TRYP-ELIM projects \[OPP1155293, INV-031337\] (PRB, RS, AH, IT, SD, PV, and EMM) and by the Belgian Directorate-general for Development Cooperation and Humanitarian Aid (EMM, RS, and PV). The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics approval was granted by the University of Warwick Biomedical and Scientific Research Ethics Committee (application number BSREC 80/21-22) to use the previously collected DRC country HAT data, provided through the framework of the WHO HAT Atlas, in this secondary modelling analysis. No new data collection took place within the scope of this modelling study. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Information about the WHO HAT Atlas data used for fitting is described in the Supplementary Information. Data cannot be shared publicly because they were aggregated from the World Health Organisation's HAT Atlas, which is under the stewardship of the WHO; our data-sharing agreement does not allow us to share that data. WHO HAT Atlas data include identifiable data. Data are available from the WHO (contact neglected.diseases@who.int or visit https://www.who.int/health-topics/human-african-trypanosomiasis/) for researchers who meet the criteria for access to confidential data, including secure computational facilities and an existing relationship to the national sleeping control program of the DRC. Time-frame for response would depend on the WHO's timelines and workloads. Clinical outcomes and costs (listed in Table 1) were simulated using estimates from the literature and are described in Supplementary Note 3: Parameter Glossary. Assumptions and estimates were parameterised according to conventions in the economic evaluation literature. All modelled outputs and code are available via Open Science Framework: https://osf.io/ezjxb/.