Skip to main content
NCBI home page
PLOS One logoLink to PLOS One
. 2022 Jun 9;17(6):e0269458. doi: 10.1371/journal.pone.0269458

Cost-analysis of COVID-19 sample collection, diagnosis, and contact tracing in low resource setting: The case of Addis Ababa, Ethiopia

Amanuel Yigezu 1,*, Samuel Abera Zewdie 2, Alemnesh H Mirkuzie 1, Adugna Abera 3, Alemayehu Hailu 4, Mesfin Agachew 1, Solomon Tessema Memirie 5
Editor: Carlos Alberto Zúniga-González6
PMCID: PMC9182302  PMID: 35679290

Abstract

Background

Ethiopia has been responding to the COVID-19 pandemic through a combination of interventions, including non-pharmaceutical interventions, quarantine, testing, isolation, contact tracing, and clinical management. Estimating the resources consumed for COVID-19 prevention and control could inform efficient decision-making for epidemic/pandemic-prone diseases in the future. This study aims to estimate the unit cost of COVID-19 sample collection, laboratory diagnosis, and contact tracing in Addis Ababa, Ethiopia.

Methods

Primary and secondary data were collected to estimate the costs of COVID-19 sample collection, diagnosis, and contact tracing. A healthcare system perspective was used. We used a combination of micro-costing (bottom-up) and top-down approaches to estimate resources consumed and the unit costs of the interventions. We used available cost and outcome data between May and December 2020. The costs were classified into capital and recurrent inputs to estimate unit and total costs. We identified the cost drivers of the interventions. We reported the cost for the following outcome measures: (1) cost per sample collected, (2) cost per laboratory diagnosis, (3) cost per sample collected and laboratory diagnosis, (4) cost per contact traced, and (5) cost per COVID-19 positive test identified. We conducted one-way sensitivity analysis by varying the input parameters. All costs were reported in US dollars (USD).

Results

The unit cost per sample collected was USD 1.33. The unit cost of tracing a contact of an index case was USD 0.66. The unit cost of COVID-19 diagnosis, excluding the cost for sample collection was USD 3.91. The unit cost of sample collection per COVID-19 positive individual was USD 11.63. The unit cost for COVID-19 positive test through contact tracing was USD 54.00. The unit cost COVID-19 DNA PCR diagnosis for identifying COVID-19 positive individuals, excluding the sample collection and transport cost, was USD 37.70. The cost per COVID-19 positive case identified was USD 49.33 including both sample collection and laboratory diagnosis costs. Among the cost drivers, personnel cost (salary and food cost) takes the highest share for all interventions, ranging from 51–76% of the total cost.

Conclusion

The costs of sample collection, diagnosis, and contact tracing for COVID-19 were high given the low per capita health expenditure in Ethiopia and other low-income settings. Since the personnel cost accounts for the highest cost, decision-makers should focus on minimizing this cost when faced with pandemic-prone diseases by strengthening the health system and using digital platforms. The findings of this study can help decision-makers prioritize and allocate resources for effective public health emergency response.

Background

On January 30, 2020, the World Health Organization (WHO) declared COVID-19 a public health emergency of international concern [1]. Globally, there were over 178 million confirmed cases of COVID-19, nearly 3.9 million deaths, and more than 163 million recovered cases reported as of 19th of June 2021. In Ethiopia, the total number of positive cases confirmed for COVID-19 reached nearly 275,000 with 4,276 deaths as of 19th of June 2021 [2].

Slowing down the transmission of the virus through a set of comprehensive strategies was crucial to reducing the morbidity and mortality from the virus. Central to these comprehensive strategies are core public health measures that break chains of person-to-person transmission, including (i) identification, isolation, testing, and clinical care for all cases, and (ii) tracing and quarantine of all contacts, and iii) use of face masks and implementation of social distancing measures [3, 4].

The public health measures emphasize the importance of early identification of incident cases to help reduce fatality [5]. Based on the epidemiology of the pandemic and capacity of testing in Ethiopia, individuals that fulfill the case definitions with acute respiratory illness (fever and at least one symptom of respiratory disease, i.e., cough, shortness of breath) and history of travel to or residence in a location reporting community transmission of COVID -19 during the 14 days prior to the onset of symptoms, were tested [6].

COVID-19 testing and contact tracing are thought to be the most effective in detecting and preventing transmission of the virus when the number of people to be tested or traced is small [7]. The volume of COVID-19 testing was inadequate in the early phase of the pandemic in Ethiopia, which could falsely reduce the number of people who would be isolated. Apart from reduced testing capacity, appropriate sample collection, turnaround time, cost, and sensitivity of the testing kits could play significant role in increasing the rate of COVID-19 detection [8]. To help improve COVID-19 case identification, in August 2020, Ethiopia implemented a community-based activity and testing program (COMBAT), a massive testing campaign against the novel coronavirus. The testing capacity has also improved following the purchase of more testing machines and locally produced COVID-19 test kits. By May 2020, more than half of the samples were collected from the community and health facilities, while specimen collection from contact tracing was about 20%. The remaining samples were collected from quarantine and isolation centers, and airports for COVID-19 diagnosis [9].

Contact tracing during the COVID-19 pandemic helps in early detection and prompt isolation of new cases. Epidemiological models indicate that the efficacy of contact tracing and isolation is dependent on the community adherence and transmission dynamics. Contact tracing involves identification, listing, and follow-up of individuals who have contact with an infected person, two days before or 14 days after the onset of symptoms of a confirmed or probable case [10]. Ethiopia followed a more stringent COVID-19 contact tracing activities until October 2020 that was loosened afterwards when there was a wide spread community transmission where contact tracing is less effective [11]. Digital contact tracing was largely used in many countries. Digital contact tracing overcomes limitations that occur in traditional contact tracing related to delays in notification, identification of contacts in public gatherings, scalability, and recall errors [12, 13]. However, these technologies have little use in resource-limited areas due to poor infrastructure for information communication technology [14].

The global community, including Ethiopia, have invested a substantial amount of money in preventing and controlling the pandemic, including sample collection, diagnosis, and tracing of contacts of positive or suspected individuals. These investments are highly resource-intensive and cause more burden to low resource settings, like sub-Saharan Africa, as the health system is not resilient in these areas [15]. Different tools for estimating the financial resource requirements for the various interventions against COVID-19 were prepared [16–18]. However, the economic costs of COVID-19 testing and contact tracing have not been estimated. Knowledge about the costs for COVID-19 interventions is beneficial in mobilizing resources, planning, and budgeting by policymakers in these settings and for use in economic evaluations of different pandemic-related interventions. The information obtained from this study could inform resource prioritization for COVID-19 response and future epidemic/pandemic situations in low-income settings. In this paper, we estimated the unit cost and total cost for COVID-19 sample collection, diagnosis, and contact tracing for low-resource settings by evaluating the case of Addis Ababa, Ethiopia.

Methods

Study setting

The study was conducted in Addis Ababa, Ethiopia. Addis Ababa is the capital city of Ethiopia, with an estimated 5 million inhabitants [19]. In the city, there are 11 hospitals and 97 health centers. Addis Ababa has the highest concentrations of COVID-19 cases in the country [20]. The Ethiopian Public Health Institute (EPHI) is the technical wing for the Federal Ministry of Health (FMoH), which is responsible for leading the COVID-19 emergency response through its Public Health Emergency Operating Center (PHEOC). The PHEOC first started its COVID-19 response measures in Addis Ababa, as the city experienced high traffic within and outside the city. By May 2020, there were 46 COVID-19 testing laboratories nationally and four of them were located at EPHI. We used one of the four laboratories at EPHI to estimate the cost of COVID-19 testing, as all the laboratories follow the same procedure [21]. The COVID-19 samples were collected from the community, health facilities, quarantine centers, airports, and isolation centers, then transported to the COVID-19 testing laboratories. In addition, contact tracing activities were also centrally coordinated by PHEOC.

Costing approach

We conducted the costing from the healthcare system perspective. We used a combination of micro-costing (bottom-up) and top-down approaches to estimate resources consumed and the unit costs of the interventions. Activities under each service were defined, measured, and valued. We estimated the costs by listing action items for each intervention, describing the specific resources needed to implement the intervention, and assigning costs to all the resources to account for the opportunity costs of the interventions. We classified the costs into capital and recurrent costs. Capital costs include buildings, equipment, and vehicles. Recurrent cost includes supplies and personnel.

Both primary and secondary data were used to estimate the costs of COVID-19 sample collection, COVID-19 diagnosis, and contact tracing. The data were collected from EPHI through the review of financial records, and expert consultations. Consultations with EPHI experts were conducted to estimate the supplies required to collect COVID-19 samples and conduct contact tracing. Supplies used for the COVID-19 laboratory diagnosis were collected from the COVID-19 laboratory unit of the EPHI, which has been conducting COVID-19 diagnosis since the pandemic began. The institute provides a meal for the laboratory personnel. Resource use for personnel, including salary, allowances, and meals, were collected from the head of the laboratory and the finance directorate within the EPHI. Equipment used for the COVID-19 laboratory was collected from the laboratory, and the price of the equipment and supplies were collected from manufacturers’ website and the Ethiopian Pharmaceutical and Supply Agency (EPSA). Equipment was annualized using a discount rate of 3% with an assumed lifespan of 5 years [22].

The institute provides transportation services for contact tracing activities, sample collection and to laboratory personnel conducting COVID-19 diagnosis. The vehicles were either owned by the institute, supplied for COVID-19 activities from different agencies, or rented from private organizations. We used rental values for all the vehicles within the institute, collected from the finance directorate within EPHI. The number of vehicles allocated to COVID-19 sample collection, diagnosis and contact tracing were collected from the transportation unit at EPHI. We used averaged rental value to estimate building costs. The rental value for building (per meter square per month) was taken from local experts who engage in activities related to rental services.

To estimate the cost per outcome; service outcome measures were taken from the laboratory conducting the COVID-19 diagnosis, from District Health Information System (DHIS), and daily COVID-19 updates by the EPHI. We collected data on the following outcomes: the number of COVID-19 samples collected, the number of laboratory diagnoses performed, the number of COVID-19 contacts traced, and the number of positive COVID-19 tests identified. We report the cost for the following outcome measures: (1) cost per sample collected, (2) cost per laboratory diagnosis, (3) cost per sample collected and laboratory diagnosis, (4) cost per contact traced, and (5) cost per COVID-19 positive test identified. We only considered cost of sample collection and testing to estimate the cost per COVID-19 positive test and it does not include the cost of contact tracing since some of the samples were collected directly (i.e. individuals with COVID-19 symptoms opting for testing) and not through contact tracing.

We conducted a one-way sensitivity analysis on the cost of identifying COVID-19 cases through laboratory diagnosis by varying the values of low and high input parameters. The lower and the higher value choice were made considering the clinical and economic feasibility of the range concerning the setting and consensus among experts [23]. All costs were collected in Ethiopian Birr (ETB) and then converted to USD (1 USD = 35.55 ETB based on the average exchange rate from the 1st of March to the end of December 2020) [24].

Ethical consideration

Ethical clearance was acquired from the Ethiopian Public Health Institute scientific and ethical review committee (EPHI-IRB-275-2020). The data is fully anonymized and informed consent from patients was not required.

Results

Unit cost of sample collection, contact tracing, and laboratory diagnosis

The total number of COVID-19 samples collected in Addis Ababa from June to December 2020 were 598,502 with 68,578 confirmed cases with a total cost of USD 797,397. Over the same period, 1,070,686 COVID-19 contacts were traced, costing USD 706,992. From May to December 2020, the COVID-19 laboratory conducted 73,955 COVID-19 DNA-PCR tests with 7,668 confirmed positive samples at the cost of USD 289,077. The monthly trends of the unit costs of sample collection, contact tracing, and testing, as shown in Fig 1, indicate that the unit cost of laboratory diagnosis was the highest compared to sample collection and contact tracing. The unit costs were higher in the first month of the interventions. The average unit costs of the sample collection, contact tracing, and laboratory diagnosis were USD 1.33, 0.66, and 3.91, respectively.

Fig 1. The unit costs of COVID-19 sample collection, contact tracing, and diagnosis over the study period.

Fig 1

Open in a new tab

* The cost of laboratory diagnosis does not include the costs of sample collection.

For sample collection, the cost of personnel takes the highest share of the total cost (around 56%), followed by vehicle cost (38%), while supplies cost contributes to only 6% of the total cost. However, the cost of building is insignificant when compared to other sample collection cost. From the total vehicle cost of USD 305,632.95, about 70% and 30% were spent to transport samples from the community and from health facilities to COVID-19 testing laboratories, respectively.

Once the laboratory received the samples, it conducted a reverse-transcription polymerase chain reaction diagnosis for COVID-19. As presented in Fig 2, for COVID-19 laboratory diagnosis, the cost of personnel was about 76% of all costs. The cost of supplies (15%) took the second-highest share of the total cost.

Fig 2. Percentage share of costs for COVID-19 laboratory diagnosis, Addis Ababa, 2020.

Fig 2

Open in a new tab

*Personnel: food cost (16%), Salary (60%).

The total cost of COVID-19 laboratory diagnosis, including sample collection, is USD 5.26 per COVID-19 test. The sample collection accounts for about 25% of the total cost. The cost of tracing a COVID-19 contact individual is USD 0.66. About 44% of this cost was attributed to transportation and 51% to personnel costs. The cost of supplies, building, and equipment constitute less than two percent of the total cost of COVID-19 contact tracing.

The cost of identifying COVID-19 positive cases

The cost of COVID-19 sample collection to identify one COVID-19 positive individual is USD 11.63. After receiving the samples, the cost per COVID-19 positive identification was USD 37.70. The cost to identify COVID-19 positive individuals including the cost of sample collection is USD 49.33. Out of the total cost of sample collection and diagnosis, the cost of sample collection takes about 24% of the total cost, while laboratory diagnosis after receiving the sample accounts for about 76% of the total cost. The cost of identifying COVID-19 positive cases through contact tracing is USD 54.00 which ranges from USD 520 in June 2020 to USD 18 in December 2020 (Fig 3).

Fig 3. Unit cost of sample collection and laboratory diagnosis to identify COVID-19 positive cases.

Fig 3

Open in a new tab

*Laboratory diagnosis cost only includes the cost after receiving the COVID-19 samples.

Sensitivity analysis results

We conducted a one-way sensitivity analysis on the discount rate and useful life years used to estimate capital costs, vehicle and building rental costs, equipment and supply costs, and personnel costs, including food, salary, and allowance payments. We used a 20% variation of the parameters to assess its impact on the cost of identifying COVID-19 positive cases after the samples are received in the laboratory. The one-way sensitivity analysis showed that the COVID-19 positivity rate is the most important parameter followed by risk allowance payment for COVID-19 workers. Next to the risk allowance, food costs, salary of the laboratory experts, and supply costs are sensitive. Fig 4 below presents the impact of different changes in the input parameters on the costs of COVID-19 laboratory diagnosis.

Fig 4. One-way sensitivity analysis on the cost of identifying COVID-19 positives through laboratory diagnosis.

Fig 4

Open in a new tab

N.B: the cost includes only resource use after the sample is transported to the laboratory unit.

Discussion

This study estimated the costs of COVID-19 sample collection, diagnosis, and contact tracing. The unit costs were USD 1.33, 0.66, and 3.91 for sample collection, diagnosis, and contact tracing, respectively. Our study found that personnel cost was the main driver of the cost for sample collection, diagnosis, and contact tracing. Vehicle cost was also the cost driver for sample collection and contact tracing. The sensitivity analysis on the input parameters of the COVID-19 diagnosis indicates that the COVID-19 positivity rate and risk allowance payment to health professionals highly impact the unit cost of identifying a COVID-19 positive individual.

Our unit cost estimate for sample collection and diagnosis of COVID-19 was USD 5.24. Of that, USD 1.33 was spent on sample collection, and USD 3.91 was accrued to diagnose COVID-19 after receiving the samples to a COVID-19 laboratory unit. These costs might vary across countries according to the type of testing and resources used [25, 26]. The cost to identify a COVID-19 positive individual was USD 49.33, of which sample collection contributed to USD 11.63, and the cost to identify a COVID-19 positive individual after receiving the sample to the laboratory is about USD 37.70. As Ethiopia scaled up its testing capacity, efficient resource allocation to COVID-19 sample collection and testing would benefit the health system. Scaling up testing capacity is cost-efficient as it averts hospitalizations due to COVID-19 disease [26].

For COVID-19 sample collection, 56% of the costs were spent on personnel, and 38% was spent on vehicles. As the number of COVID-19 testing laboratories is limited, the costs associated with sample collection bore a high burden to the health sector because of the distance travelled to transport the samples and personnel related costs. These costs contribute to a third of the total laboratory testing cost, indicating the health system might avert a large amount of investment had there been access to nearby laboratory facilities that conduct COVID-19 testing.

Share of the costs at the COVID-19 laboratory after receiving samples were about 76% for personnel (60% salary/allowance and 16% food) and 15% for the cost of supplies. Allowance payment and meal price that were not usual cost components in the health system now take a significant amount of the resources. Allowance payment for the health workers on COVID-19 takes more than fivefold of their average salary. The sensitivity analysis also indicates that the unit cost of identifying COVID-19 cases is determined mainly by the COVID-19 positivity rate and payment of risk allowance for personnel. If the health system is stronger and able to include COVID-19 laboratory testing in the routine health system, we could save resources that are invested as risk payment for health professionals. This might require a resilient health system that can effectively and efficiently tackle epidemics/pandemics and, therefore, the need for health system strengthening.

The cost of tracing a contact of COVID-19 infected individual was USD 0.66; 51% of which was personnel salary and allowance, followed by costs of vehicles, which was about 44% of the total cost. As we considered the vehicle costs in rental value, the costs associated with transportation might be over-estimated. Our cost estimate is less than the unit cost estimate from a previous study in South Africa, which estimated the cost per contact to be USD 2.67 in their context. This variance in cost may be due to differences in the methods used to estimate the unit costs [27]. In Ethiopia, however, it costed about USD 54.00 per COVID-19 positive case identified through contact tracing. The cost per COVID-19 positive case identified was very high in the first few months when the pandemic was not widely distributed in the community. Improved contact tracing methods, like the use of digital contact tracing, would also reduce the cost of tracing a COVID-19 suspect. This would also increase the efficiency and quality of the contact tracing activities by improving the identification of contacts in public gatherings and reducing recall errors [13].

As the community distribution of the pandemic increases, the total cost of testing and contact tracing will be very high as there would be more COVID-19 suspects who may have contracted the virus. However, the efficacy of these two interventions would decrease [7]. Therefore, the economic benefit of testing and contact tracing of COVID-19 suspects would be less compared to their implementation in the early phase of the pandemic. As this study is only aimed at estimating the costs of tracing a COVID-19 contact and testing, we recommend further studies that combine the costs relative to the effects for different sets of interventions during different phases of the pandemic.

The introduction of vaccines can vastly reduce the transmission and thereby the economic costs associated with other COVID-19 interventions, including sample collection, testing, and contact tracing [28, 29]. Ethiopia has recently started vaccinating its community against COVID-19. It is estimated that about USD 382.3 million is needed for the COVID-19 vaccine procurement, delivery, and health system strengthening [30]. As of May 2021, about 2 million people were tested for COVID-19 in Ethiopia. The findings from this study will provide input to estimating the potential cost savings that arise from the introduction of vaccines in low-resource settings, including Ethiopia. For example, the direct healthcare impact of resource diversion from other essential health services would have a tremendous economic impact on the health system [31, 32]. Therefore, we recommend further studies to assess the opportunity cost of interventions against COVID-19 on the health system in low and middle-income countries.

The response against COVID-19 pandemic has disrupted the health system of countries. Despite making remarkable progress in achieving the millennium development goals, the COVID-19 may hamper developing counties’ progress towards the Sustainable Development Goals (SDG) [33]. Ethiopia’s per capita spending was $33.2 in 2016/17. It is estimated that additional per capita spending of USD 41 is needed each year to make progress toward SDG in low and middle-income countries [34]. The resource diversion from the already weak per capita health spending to COVID-19 response might even cancel the MDG era’s achievements. To protect the health of the society, maintaining essential health services was a significant recommendation especially in a resource-limited setting that could be overburdened by the COVID-19 pandemic [35]. To recommence and keep the non-COVID-19 essential services in pace, Ethiopia has put approaches for delivering those services [36].

This study is not without limitations. First and foremost, the available data for contact tracing and sample collection from March-May 2020 were not complete. Therefore, we included data for laboratory diagnosis starting from the month of May while data for contact tracing and sample collection from June-December 2020. This may result in incomplete cost information. In addition, since the application of COVID-19 activities was changing in its approach, we might have missed capturing all of the cost at each level due to recall bias and poor recording of the expenses associated with the COVID-19. For example, most of the contact tracing activities before September were intense. Because of multiple administrative units within the EPHI, it was difficult to estimate and allocate utilities such as electricity, water, and telecommunication costs. Moreover, our study did not consider the possibility that samples might be retested again. This might also underestimate the unit cost estimate of our findings. This study did not consider the costs of other major interventions, including the costs of quarantine centers, establishing and expansion of COVID-19 treatment centers and diagnostic facilities, enforcement of COVID-19 prevention and infection prevention and control (IPC) measures, and promotion of disease prevention and control. Furthermore, as this study focus in Addis Ababa, we recommend additional studies to be conducted at the national level.

Conclusion

This study attempted to estimate the cost of COVID-19 sample collection, testing, and contact tracing in a low-income country, such as Ethiopia. The findings indicate that the cost of interventions against pandemic-prone disease could be a substantial burden to the health system in such settings. Strategies that support efficient use of resource when faced with a pandemic-prone disease are crucial. This study will support the allocation of resources within the health system in low-income countries by identifying feasible and justifiable areas to reduce costs. We found that the personnel cost for COVID-19 testing and contact tracing is high due to additional payment for risk allowance and food costs and salary. The unit cost estimates for COVID-19 sample collection, testing and contact tracing could be used as an input by researchers for conducting economic evaluation of COVID-19 interventions. In addition, it may help policy and decision makers for planning and budgeting on future pandemic response and control measures.

Supporting information

S1 Appendix

(DOCX)

Click here for additional data file. (49.7KB, docx)

Acknowledgments

We would like to thank the staff of the Ethiopian Public Health Institute (EPHI) for their support on this study.

List of abbreviations

ACEPS

Addis Center for Ethics and Priority Setting

COVID-19

Coronavirus disease-19

EPHI

Ethiopian Public Health Institute

FMoH

Federal Ministry of health

NDMC

National Data Management Center for health

PHEOCIMS

Public Health Emergency Operation Center Incidence Management Structure

USD

United States Dollar

WHO

World Health Organization

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

References

  • 1.Global Surveillance for human infection with coronavirus disease (COVID-19). Interim Guid [Internet]. (February):27–9. Available from: https://www.who.int/publications-detail/global-surveillance-for-human-infection-with-novel-coronavirus-(2019-ncov) [Internet]. 2020.
  • 2.www.worldometers. worldometers: COVID-19 CORONAVIRUS PANDEMIC Cases, Deaths and Recovered Report. 2021;263.
  • 3.Overview of public health and social measures in the context of COVID-19. World Heal Organ 2020. 2020;(May):1–8. [Internet]. [Google Scholar]
  • 4.World Health Organization. Contact tracing in the context of COVID-19. Interim guidance. Pediatr i Med Rodz. 2020;16(1):33–9. [Google Scholar]
  • 5.Siedner MJ, Gostin LO, Cranmer HH, Kraemer JD. Strengthening the Detection of and Early Response to Public Health Emergencies: Lessons from the West African Ebola Epidemic. PLOS Medicine. 2015;12(3):e1001804. doi: 10.1371/journal.pmed.1001804 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Institute EPH. Interim National Strategy and Guidance for the Laboratory Diagnosis of COVID-19 in Ethiopia, May 2020. 2021 [cited 2021 18-04-21]. Available from: https://covid19.ephi.gov.et/document/. [Google Scholar]
  • 7.Rowthorn R, Maciejowski J. A cost–benefit analysis of the COVID-19 disease. Oxford Review of Economic Policy. 2020;36(Supplement_1):S38–S55. [Google Scholar]
  • 8.Lyng GD, Sheils NE, Kennedy CJ, Griffin DO, Berke EM. Identifying optimal COVID-19 testing strategies for schools and businesses: Balancing testing frequency, individual test technology, and cost. PLOS ONE. 2021;16(3):e0248783. doi: 10.1371/journal.pone.0248783 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Ethiopian Public Health Institute. EPHI_PHEOC_COVID-19_Weekly_Bulletin_31_English_11302020 2021. Available from: https://covid19.ephi.gov.et/download/ephi_pheoc_covid-19_weekly_bulletin_31_english_11302020/.
  • 10.Hellewell J, Abbott S, Gimma A, Bosse NI, Jarvis CI, Russell TW, et al. Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts. The Lancet Global health. 2020 Apr;8(4):e488–e96. doi: 10.1016/S2214-109X(20)30074-7 . Pubmed Central PMCID: PMC7097845. Epub 2020/03/03. eng. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Khanna RC, Cicinelli MV, Gilbert SS, Honavar SG, Murthy GSV. COVID-19 pandemic: Lessons learned and future directions. Indian journal of ophthalmology. 2020 May;68(5):703–10. doi: 10.4103/ijo.IJO_843_20 . Pubmed Central PMCID: PMC7350475. Epub 2020/04/23. eng. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Jaca A, Iwu CJ, Wiysonge CS. Cochrane corner: digital contact tracing technologies in epidemics. The Pan African medical journal. 2020;37(Suppl 1):8. doi: 10.11604/pamj.supp.2020.37.8.25986 . Pubmed Central PMCID: PMC7704351. Epub 2020/12/10. eng. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Kleinman RA, Merkel C. Digital contact tracing for COVID-19. CMAJ. 2020;192(24):E653–E6. doi: 10.1503/cmaj.200922 . Epub 05/27. eng. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Mbunge E. Integrating emerging technologies into COVID-19 contact tracing: Opportunities, challenges and pitfalls. Diabetes & metabolic syndrome. 2020. Nov-Dec;14(6):1631–6. doi: 10.1016/j.dsx.2020.08.029 . Pubmed Central PMCID: PMC7833487. Epub 2020/09/07. eng. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Torres-Rueda S, Sweeney S, Bozzani F, Vassall A. The health sector cost of different policy responses to COVID-19 in low- and middle-income countries. medRxiv. 2020:2020.08.23.20180299. [Google Scholar]
  • 16.World Health Organization. COVID-19 Essential Supplies Forecasting Tool. [August 2021]. Available from: https://www.who.int/publications/m/item/covid-19-essential-supplies-forecasting-tool#. [Google Scholar]
  • 17.World Health Organization. WHO. Health Workforce Estimator (HWFE). [cited 2021 May]. Available from: https://www.euro.who.int/en/health-topics/Health-systems/pages/strengthening-the-health-system-response-to-covid-19/surge-planning-tools/health-workforce-estimator-hwfe#:~:text=The%20Health%20Workforce%20Estimator%20(HWFE,and%20critical%20patients%20per%20day.
  • 18.World Health Organization. Emergency Global Supply Chain System (COVID-19) catalogue. 2021. [cited 2021 May]. Available from: https://www.who.int/publications/m/item/emergency-global-supply-chain-system-covid-19-catalogue. [Google Scholar]
  • 19.World Population Review. Addis Ababa Population 2021 2021. Available from: https://worldpopulationreview.com/world-cities/addis-ababa-population.
  • 20.Ethiopian Public Health Institute. Ethiopia COVID-19 monitoring platform 2021. Available from: http://www.covid19.et/covid-19/Home/DataPresentationByGraph.
  • 21.Abera A, Belay H, Zewude A, Gidey B, Nega D, Dufera B, et al. Establishment of COVID-19 testing laboratory in resource-limited settings: challenges and prospects reported from Ethiopia. Glob Health Action. 2020;13(1):1841963–. doi: 10.1080/16549716.2020.1841963 . eng. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.World Health O, Baltussen RMPM, Adam T, Tan-Torres Edejer T, Hutubessy RCW, Acharya A, et al. Making choices in health: WHO guide to cost-effectiveness analysis / edited by Tan-Torres Edejer T.… [et al. ]. Geneva: World Health Organization; 2003. [Google Scholar]
  • 23.Drummond M. Methods for the economic evaluation of health care programmes. 2017. [Google Scholar]
  • 24.Commercial Bank of Ethiopia. Summary Exchange Rate Average From 16-Mar-2020 to 30-Nov-2020. https://combanketh.et/summary (11/02/2021).
  • 25.Neilan AM, Losina E, Bangs AC, Flanagan C, Panella C, Eskibozkurt GE, et al. Clinical Impact, Costs, and Cost-Effectiveness of Expanded SARS-CoV-2 Testing in Massachusetts. Clinical Infectious Diseases. 2020. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Sousa-Pinto B, Fonseca JA, Costa-Pereira A, Rocha-Gonçalves FN. Is scaling-up COVID-19 testing cost-saving? medRxiv. 2020:2020.03.22.20041137. [Google Scholar]
  • 27.Reddy KP, Shebl FM, Foote JHA, Harling G, Scott JA, Panella C, et al. Cost-effectiveness of public health strategies for COVID-19 epidemic control in South Africa: a microsimulation modelling study. The Lancet Global Health. 2021. 2021/02/01/;9(2):e120–e9. doi: 10.1016/S2214-109X(20)30452-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.Shaker M, Abrams EM, Greenhawt M. A Cost-Effectiveness Evaluation of Hospitalizations, Fatalities, and Economic Outcomes Associated with Universal Versus Anaphylaxis Risk-Stratified COVID-19 Vaccination Strategies. The journal of allergy and clinical immunology In practice. 2021. Mar 9. doi: 10.1016/j.jaip.2021.02.054 . Pubmed Central PMCID: PMC7942189. Epub 2021/03/13. eng. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Sookaromdee P, Wiwanitkit V. New COVID-19 Vaccines, Its Cost and Shelf Life: A Cost Effectiveness Analysis. Archives of medical research. 2020. Dec 23. doi: 10.1016/j.arcmed.2020.12.008 . Pubmed Central PMCID: PMC7755566. Epub 2021/01/25. eng. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Ministry of Health E. Ethiopia National Deployment and Vaccination Plan for COVID-19 Vaccines. 2021. [Google Scholar]
  • 31.McQuaid CF, McCreesh N, Read JM, Sumner T, Houben RMGJ, White RG, et al. The potential impact of COVID-19-related disruption on tuberculosis burden. European Respiratory Journal. 2020:2001718. doi: 10.1183/13993003.01718-2020 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Roberton T, Carter ED, Chou VB, Stegmuller AR, Jackson BD, Tam Y, et al. Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. The Lancet Global health. 2020. Jul;8(7):e901–e8. doi: 10.1016/S2214-109X(20)30229-1 . Pubmed Central PMCID: PMC7217645. Epub 2020/05/15. eng. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Verguet S, Hailu A, Eregata GT, Memirie ST, Johansson KA, Norheim OF. Toward universal health coverage in the post-COVID-19 era. Nature Medicine. 2021 2021/03/01;27(3):380–7. doi: 10.1038/s41591-021-01268-y [DOI] [PubMed] [Google Scholar]
  • 34.Liaropoulos L, Goranitis I. Health care financing and the sustainability of health systems. Int J Equity Health. 2015;14:80–. doi: 10.1186/s12939-015-0208-5 . eng. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Blanchet K, Alwan A, Antoine C, Cros MJ, Feroz F, Amsalu Guracha T, et al. Protecting essential health services in low-income and middle-income countries and humanitarian settings while responding to the COVID-19 pandemic. BMJ Global Health. 2020;5(10):e003675. doi: 10.1136/bmjgh-2020-003675 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Federal Ministry of Health. Health Sector Transformation Plan 2020/21-2024/25 (2013 EFY—2017 EFY), Addis Ababa Ethiopia. 2020.

Decision Letter 0

Carlos Alberto Zúniga-González

11 Oct 2021

PONE-D-21-20233

Cost-analysis of COVID-19 sample collection, diagnosis, and contact tracing in low resource setting: the case of Addis Ababa, Ethiopia

PLOS ONE

Dear Dr. Amanuel Yigezu,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Nov 25 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Carlos Alberto Zúniga-González, Ph.D

Academic Editor

PLOS ONE

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Additional Editor Comments (if provided):

Dear author, the main concern with the paper is that it is very vague on the sources of the data, making it hard both to replicate and to get a sense of how much the results might be able to generalize, say, across Ethiopia. I therefore recommend that the authors provide more specific information about data sources, perhaps in a table form, to enable replication to the greatest extent possible.

I suggest this references:

1) Dios-Palomares, R ; Alcaide, D ; Diz, J ; Jurado, M ; Prieto, A ; Morantes, M ; Zuniga, C.A. (2015). Analysis of the Efficiency of Farming Systems in Latin America and the Caribbean Considering Environmental Issues REVISTA CIENTIFICA-FACULTAD DE CIENCIAS VETERINARIAS, Volume: 25 Issue: 1 Pages: 43-50 https://publons.com/publon/3106827/

2) Zuniga González, C. A. (2020). Total factor productivity growth in agriculture: Malmquist index analysis of 14 countries, 1979-2008. Revista Electrónica De Investigación En Ciencias Económicas, 8(16), 68–97. https://doi.org/10.5377/reice.v8i16.10661

3) Blanco-Orozco, N. V., Arce-Díaz, E., & Zúñiga-Gonzáles, C. (2015). Integral assessment (financial, economic, social, environmental and productivity) of using bagasse and fossil fuels in power generation in Nicaragua. Tecnología En Marcha Journal, 28(4), pág. 94–107. https://doi.org/10.18845/tm.v28i4.2447

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Major comments and questions:

Overall: Thank you for the opportunity to review this manuscript. I appreciate the authors’ contributions with this important study to the field of public health and public health economics specifically. The study provides a straightforward analysis of the costs associated with covid-19 sample collection, diagnosis, and contact tracing; however, I have a few considerations to improve the manuscript prior to it being accepted for publication.

1. The introduction section provides a detailed background and justification for the study, and is well written.

2. The methods section needs to be improved as there is not enough detail of the costing approach. First, please clarify the actual study perspective. You list that it is a healthcare provider perspective, but you include more than just provider-related costs. Provider costs are only relevant to the staff providing services and typically only includes salary and time. I believe your study is an actual healthcare sector or system perspective as you include direct provider and payer costs related to sample collection, diagnosis, and contact tracing, not just those costs directly related to the provider. The health sector perspective includes all providers and payers and assumes that all medical costs are paid by the health sector. Second, I do not know what costing method you used in the study. You stated that “activities under each service were defined, measured, and valued. We estimated the costs by listing action items for each intervention, describing the specific resources needed to implement the intervention, and assigning costs to all the resources based on opportunity costs used for the intervention”. Did you rely on a macro-costing method, activity-based costing, or micro-costing for this? Please clarify this and provide more information on your collection procedures. Also, it would be helpful to include your cost inventory as an appendix or supplementary file to review all of the resources under each activity that are included in your costs. You’ve described in general what was included, but I still don’t know what specifically makes up all of the resources and subsequent costs in the study. Third, I am unsure what makes up the cost for identifying a positive Covid-19 case? I would assume that the costs of sample collection, laboratory diagnosis, and contact tracing are included, but aggregating the costs of these three from your results does not add up to the costs for identifying a positive case in the text. The details for this are missing in the methods and need to be included.

3. The results section has some inconsistencies. Figure 1: In the text you state that this data is from May – December; however the figure only shows June – December. Please add footnotes for figure 1 to explain why data for May is not shown on the figure. Also, for figure 1, you have added “sample collection and diagnosis” as a result to share. You only state throughout the text that you are assessing the three outcomes independently (1. sample collection, 2. Laboratory diagnosis, and 3. Contact tracing). What is the value added to show us sample collection and diagnosis combined?

Figure 2: Percentages are better visualized in a pie chart or donut chart, or a stacked bar chart, since you are trying to show proportions out of a whole. The way it is presented here would draw immediate attention to the x-axis scale where we see it does not total 100%. For figure 2 I also recommend adding footnotes that provide more details of the items/resources that are included in the costs for those categories. I have seen other studies provide this as the general perspective is the table should provide enough detail to stand alone.

4. The discussion is written well and informative. My only suggestion it to add more about how Ethiopia can use these results for budgeting and priority planning and speak to the benefit of the study for future economic evaluation.

Additional Comments:

1. The references with website links need to be reviewed. I received an error for the links for references #1, 17, and 18 when attempting to open.

Reviewer #2: My main concern with the paper is the non-transparency of the data. The costs are clearly communicated, but it is oftentimes unclear where the data comes from. Further, partly because it is unclear where the data come from, it is also unclear whether the results are expected to be representative for Ethiopia as a whole, or just Addis Ababa. And are different components of the total cost estimates more/less representative of Addis Ababa or Ethiopia?

The study should be replicable to the greatest extent possible, and right now, the sources of the data are so vague that it would be very hard for someone else to replicate the study. For instance, it says in the first paragraph under the section "Costing approach" that "The data was collected from the EPHI through the review of financial records, literature, and expert consultation." This is very vague -- what data came from what source, and what were the sources more precisely? And, another example: further down in the same section, rental values are discussed, but where does the rental value data come from? It says it was collected from "local experts who engage in activities related to rental services." What does that mean, and how can I find that data?

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2022 Jun 9;17(6):e0269458. doi: 10.1371/journal.pone.0269458.r002

Author response to Decision Letter 0

10 Feb 2022

January 29, 2022

Dr. Sanjay Kumar Singh Patel

Academic Editor

PLOS ONE

Dear Editors,

We are submitting our revised manuscript entitled "Cost-analysis of COVID-19 sample collection, diagnosis, and contact tracing in low resource setting: the case of Addis Ababa, Ethiopia " (PONE-D-21-20233) to PLOS ONE.

We would like to thank the editor and reviewers for the constructive comments and suggestions which have helped to strengthen our work substantially.

We have now included “Inputs and data sources” section in the supporting document to provide specific information about the data sources that we have used and to enable replication of our study findings to the greatest extent possible.

Below, we have provided a detailed point-by-point response to all comments and suggestions raised in the review.

Thank you very much for your consideration of our manuscript.

Sincerely,

Amanuel Yigezu, on behalf of the authors

 

Point-by-point response to the reviewers’ comments

Reviewer #1:

The introduction section provides a detailed background and justification for the study, and is well written.

Authors’ response: We thank the reviewer for his/her positive comments on our manuscript and the additional comments are addressed below.

The methods section needs to be improved as there is not enough detail of the costing approach. First, please clarify the actual study perspective. You list that it is a healthcare provider perspective, but you include more than just provider-related costs. Provider costs are only relevant to the staff providing services and typically only includes salary and time. I believe your study is an actual healthcare sector or system perspective as you include direct provider and payer costs related to sample collection, diagnosis, and contact tracing, not just those costs directly related to the provider. The health sector perspective includes all providers and payers and assumes that all medical costs are paid by the health sector.

Authors’ response: Thank you for your comments. We agree with the reviewer that it is a health care system perspective and currently, it reads as “health care system perspective” on the relevant sections of the paper (line 33 and 127). Further more, we have now improved the methods section to clarify on the costing approach. Please see under Methods, “Costing approach” (line 127-129).

Second, I do not know what costing method you used in the study. You stated that “activities under each service were defined, measured, and valued. We estimated the costs by listing action items for each intervention, describing the specific resources needed to implement the intervention, and assigning costs to all the resources based on opportunity costs used for the intervention”. Did you rely on a macro-costing method, activity-based costing, or micro-costing for this? Please clarify this and provide more information on your collection procedures. Also, it would be helpful to include your cost inventory as an appendix or supplementary file to review all of the resources under each activity that are included in your costs. You’ve described in general what was included, but I still don’t know what specifically makes up all of the resources and subsequent costs in the study.

Authors’ response: Thank you for raising this important point. We have now included the following sentence under Method, Costing approach, lines 127-129: “We used a combination of micro-costing (bottom-up) and top-down approaches to estimate resource consumed and the unit costs of the interventions”. We have also included a cost inventory in the supporting document. We have also modified the section describing our data collection procedure (Line 137-157).

Third, I am unsure what makes up the cost for identifying a positive Covid-19 case? I would assume that the costs of sample collection, laboratory diagnosis, and contact tracing are included, but aggregating the costs of these three from your results does not add up to the costs for identifying a positive case in the text. The details for this are missing in the methods and need to be included.

Authors’ response: Thank you for raising this point. We chose not to include the cost of contact tracing since not all samples are collected through contact tracing. We therefore used only (sample collection and lab diagnosis to inform the cost per COVID-19 test and the cost per COVID-19 positive identification. We have now included this clarification in the method section “We only considered cost of sample collection and testing to estimate the cost per COVID-19 positive test; it does not include the cost of contact tracing since some of the samples are collected directly (i.e. from individuals with COVID-19 symptoms opting for testing) and not through contact tracing.”

The results section has some inconsistencies. Figure 1: In the text you state that this data is from May – December; however the figure only shows June – December. Please add footnotes for figure 1 to explain why data for May is not shown on the figure.

Authors’ response: Thank you for your comment. Even though data were collected for the period May to December, complete data for May were not available for contact tracing and sample collection. However, data were available for laboratory diagnosis from May to December. We have now added the following under the limitation section: Line 294-296 “This study is not without limitations. First and foremost, the available data for contact tracing and sample collection from March- May 2020 were not complete. Therefore, we included data for laboratory diagnosis starting from the month of May while data for contact tracing and sample collection from June-December, 2020”.

Also, for figure 1, you have added “sample collection and diagnosis” as a result to share. You only state throughout the text that you are assessing the three outcomes independently (1. sample collection, 2. Laboratory diagnosis, and 3. Contact tracing). What is the value added to show us sample collection and diagnosis combined?

Authors’ response: Thank you for the comment. We wanted to add this information to inform the combined cost of COVID-19 sample collection and laboratory diagnosis. To clarify the point we have added the following description: “We reported the cost for the following outcome measures: (1) cost per sample collected, (2) cost per laboratory diagnosis, (3) cost per sample collected and laboratory diagnosis, (4) cost per contact traced, and (5) cost per COVID-19 positive test identified.”

Figure 2: Percentages are better visualized in a pie chart or donut chart, or a stacked bar chart, since you are trying to show proportions out of a whole. The way it is presented here would draw immediate attention to the x-axis scale where we see it does not total 100%. For figure 2 I also recommend adding footnotes that provide more details of the items/resources that are included in the costs for those categories. I have seen other studies provide this as the general perspective is the table should provide enough detail to stand alone.

Authors’ response: Thank you for the comment. We have now changed the figure to a pie chart. However, the item/resources used for the cost category were difficult to add in the footnote, as the supplies and equipment used for laboratory testing are several in numbers. We have included the list of supplies and equipment in the supporting document.

The discussion is written well and informative. My only suggestion it to add more about how Ethiopia can use these results for budgeting and priority planning and speak to the benefit of the study for future economic evaluation.

Authors’ response: Thank you for your comments. We have now included the following in the conclusion section (please see Conclusion section, lines 319-321-309): “The unit cost estimates for COVID-19 sample collection, testing and contact racing could be used as an input by researchers for conducting economic evaluation of COVID-19 interventions. In addition, it may help policy and decision makers for planning and budgeting on future pandemic response and control measures. ”

The references with website links need to be reviewed. I received an error for the links for references #1, 17, and 18 when attempting to open.

Authors’ response: Thank you for pointing out these errors. We have corrected the reference links. Please see reference #1, 17 and 18.

Reviewer #2:

My main concern with the paper is the non-transparency of the data. The costs are clearly communicated, but it is oftentimes unclear where the data comes from. Further, partly because it is unclear where the data come from, it is also unclear whether the results are expected to be representative for Ethiopia as a whole, or just Addis Ababa. And are different components of the total cost estimates more/less representative of Addis Ababa or Ethiopia?

Authors’ response: Thank you for your comment. We have now included a table to provide specific information about the data sources that we have used and to enable replication of our study findings to the greatest extent. Please see supporting document: I. Input and data sources.

The study should be replicable to the greatest extent possible, and right now, the sources of the data are so vague that it would be very hard for someone else to replicate the study. For instance, it says in the first paragraph under the section "Costing approach" that "The data was collected from the EPHI through the review of financial records, literature, and expert consultation." This is very vague -- what data came from what source, and what were the sources more precisely? And, another example: further down in the same section, rental values are discussed, but where does the rental value data come from? It says it was collected from "local experts who engage in activities related to rental services." What does that mean, and how can I find that data?

Authors’ response: Thank you for your comment. We have provided the source of data in the supplementary part of the manuscripts (Supporting document). We also acknowledged the outcome of the study might only be representative for Addis Ababa. To address the comment we have now added the following: “Furthermore, as this study focus in Addis Ababa, we recommend additional studies to be conducted at the national level”. Please see line 3125-317.

Attachment

Submitted filename: Response to reviewers..docx

Click here for additional data file. (28.5KB, docx)

Decision Letter 1

Carlos Alberto Zúniga-González

11 Apr 2022

PONE-D-21-20233R1Cost-analysis of COVID-19 sample collection, diagnosis, and contact tracing in low resource setting: the case of Addis Ababa, EthiopiaPLOS ONE

Dear Dr. Amanuel Yigezu

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by May 26 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Carlos Alberto Zúniga-González, Ph.D

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Dear authors, attend to the recommendations of the reviewer, and I will be waiting for your improvements as soon as possible to continue the process. In general I have reviewed that they have conducted very well the comments of the reviewers.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors have addressed my previous comments adequately and I recommend publication with the following minor revisions. Recommendations for the authors are to present the cost results in the same order as they are mentioned in the methods and to make sure the abstract method and results are consistent with this as well. This will add clarity in reading the results. Secondly, the authors need to report all costs as they are shown on the figures. For example, personnel costs are separate from food costs in figure 2, so this should be the way it is reported in text. Lastly, there are a few grammatical errors and misspellings throughout this version and I recommend the authors review for grammatical errors and edit as needed prior to publication.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2022 Jun 9;17(6):e0269458. doi: 10.1371/journal.pone.0269458.r004

Author response to Decision Letter 1

18 May 2022

May 15, 2022

Dr. Sanjay Kumar Singh Patel

Academic Editor

PLOS ONE

Dear Editors,

We are submitting our revised manuscript entitled "Cost-analysis of COVID-19 sample collection, diagnosis, and contact tracing in low resource setting: the case of Addis Ababa, Ethiopia " (PONE-D-21-20233) to PLOS ONE.

We would like to thank the editor and reviewers for the constructive comments and suggestions which have helped to strengthen our work substantially.

Below, we have provided a detailed point-by-point response to all comments and suggestions raised in the review.

Thank you very much for your consideration of our manuscript.

Sincerely,

Amanuel Yigezu, on behalf of the authors

 

Point-by-point response to the reviewer’s comments

Reviewer #1:

The authors have addressed my previous comments adequately and I recommend publication with the following minor revisions. Recommendations for the authors are to present the cost results in the same order as they are mentioned in the methods and to make sure the abstract method and results are consistent with this as well. This will add clarity in reading the results.

Authors’ response: We thank the reviewer for his/her positive comments on our manuscript. We have now presented the cost results in the same order as they are mentioned in the methods both in the abstract and methods sections.

Secondly, the authors need to report all costs as they are shown on the figures. For example, personnel costs are separate from food costs in figure 2, so this should be the way it is reported in text.

Authors’ response: Thank you for the comment. We have now reported food costs in figure 2 the way it is reported in text.

Lastly, there are a few grammatical errors and misspellings throughout this version and I recommend the authors review for grammatical errors and edit as needed prior to publication

Authors’ response: Thank you for the comment. We have now edited the manuscript to correct grammatical error.

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file. (21.2KB, docx)

Decision Letter 2

Carlos Alberto Zúniga-González

23 May 2022

Cost-analysis of COVID-19 sample collection, diagnosis, and contact tracing in low resource setting: the case of Addis Ababa, Ethiopia

PONE-D-21-20233R2

Dear Dr. Amanuel Yigezu,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Carlos Alberto Zúniga-González, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Congratulations, all observatios for reviewer have been incorpated.

Reviewers' comments:

Acceptance letter

Carlos Alberto Zúniga-González

30 May 2022

PONE-D-21-20233R2

Cost-analysis of COVID-19 sample collection, diagnosis, and contact tracing in low resource setting: the case of Addis Ababa, Ethiopia

Dear Dr. Yigezu:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Prof. Carlos Alberto Zúniga-González

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Appendix

    (DOCX)

    Click here for additional data file. (49.7KB, docx)
    Attachment

    Submitted filename: Response to reviewers..docx

    Click here for additional data file. (28.5KB, docx)
    Attachment

    Submitted filename: Response to reviewers.docx

    Click here for additional data file. (21.2KB, docx)

    Data Availability Statement

    All relevant data are within the paper and its Supporting Information files.

    Articles from PLoS ONE are provided here courtesy of PLOS

    RESOURCES