Antenatal Syphilis Screening Using Point-of-Care Testing in Sub-Saharan African Countries: A Cost-Effectiveness Analysis
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{"title"=>"Antenatal Syphilis Screening Using Point-of-Care Testing in Sub-Saharan African Countries: A Cost-Effectiveness Analysis", "type"=>"journal", "authors"=>[{"first_name"=>"Andreas", "last_name"=>"Kuznik", "scopus_author_id"=>"23568159200"}, {"first_name"=>"Mohammed", "last_name"=>"Lamorde", "scopus_author_id"=>"24069027300"}, {"first_name"=>"Agnes", "last_name"=>"Nyabigambo", "scopus_author_id"=>"55948942200"}, {"first_name"=>"Yukari C.", "last_name"=>"Manabe", "scopus_author_id"=>"7102232050"}], "year"=>2013, "source"=>"PLoS Medicine", "identifiers"=>{"pmid"=>"24223524", "doi"=>"10.1371/journal.pmed.1001545", "sgr"=>"84889016938", "isbn"=>"1549-1676 (Electronic)\r1549-1277 (Linking)", "scopus"=>"2-s2.0-84889016938", "issn"=>"15491277", "pui"=>"370401978"}, "id"=>"c1820509-fe06-3c3b-a384-b02e588cde4d", "abstract"=>"BACKGROUND: Untreated syphilis in pregnancy is associated with adverse clinical outcomes for the infant. Most syphilis infections occur in sub-Saharan Africa (SSA), where coverage of antenatal screening for syphilis is inadequate. Recently introduced point-of-care syphilis tests have high accuracy and demonstrate potential to increase coverage of antenatal screening. However, country-specific cost-effectiveness data for these tests are limited. The objective of this analysis was to evaluate the cost-effectiveness and budget impact of antenatal syphilis screening for 43 countries in SSA and estimate the impact of universal screening on stillbirths, neonatal deaths, congenital syphilis, and disability-adjusted life years (DALYs) averted. METHODS AND FINDINGS: The decision analytic model reflected the perspective of the national health care system and was based on the sensitivity (86%) and specificity (99%) reported for the immunochromatographic strip (ICS) test. Clinical outcomes of infants born to syphilis-infected mothers on the end points of stillbirth, neonatal death, and congenital syphilis were obtained from published sources. Treatment was assumed to consist of three injections of benzathine penicillin. Country-specific inputs included the antenatal prevalence of syphilis, annual number of live births, proportion of women with at least one antenatal care visit, per capita gross national income, and estimated hourly nurse wages. In all 43 sub-Saharan African countries analyzed, syphilis screening is highly cost-effective, with an average cost/DALY averted of US$11 (range: US$2-US$48). Screening remains highly cost-effective even if the average prevalence falls from the current rate of 3.1% (range: 0.6%-14.0%) to 0.038% (range: 0.002%-0.113%). Universal antenatal screening of pregnant women in clinics may reduce the annual number of stillbirths by up to 64,000, neonatal deaths by up to 25,000, and annual incidence of congenital syphilis by up to 32,000, and avert up to 2.6 million DALYs at an estimated annual direct medical cost of US$20.8 million. CONCLUSIONS: Use of ICS tests for antenatal syphilis screening is highly cost-effective in SSA. Substantial reduction in DALYs can be achieved at a relatively modest budget impact. In SSA, antenatal programs should expand access to syphilis screening using the ICS test. Please see later in the article for the Editors' Summary.", "link"=>"http://www.mendeley.com/research/antenatal-syphilis-screening-using-pointofcare-testing-subsaharan-african-countries-costeffectivenes-1", "reader_count"=>80, "reader_count_by_academic_status"=>{"Unspecified"=>3, "Professor > Associate Professor"=>5, "Librarian"=>2, "Researcher"=>19, "Student > Doctoral Student"=>4, "Student > Ph. D. Student"=>8, "Student > Postgraduate"=>4, "Student > Master"=>20, "Other"=>5, "Student > Bachelor"=>9, "Lecturer"=>1}, "reader_count_by_user_role"=>{"Unspecified"=>3, "Professor > Associate Professor"=>5, "Librarian"=>2, "Researcher"=>19, "Student > Doctoral Student"=>4, "Student > Ph. D. Student"=>8, "Student > Postgraduate"=>4, "Student > Master"=>20, "Other"=>5, "Student > Bachelor"=>9, "Lecturer"=>1}, "reader_count_by_subject_area"=>{"Unspecified"=>9, "Nursing and Health Professions"=>7, "Medicine and Dentistry"=>38, "Agricultural and Biological Sciences"=>6, "Business, Management and Accounting"=>2, "Veterinary Science and Veterinary Medicine"=>1, "Psychology"=>1, "Social Sciences"=>9, "Computer Science"=>1, "Immunology and Microbiology"=>2, "Decision Sciences"=>1, "Economics, Econometrics and Finance"=>3}, "reader_count_by_subdiscipline"=>{"Medicine and Dentistry"=>{"Medicine and Dentistry"=>38}, "Social Sciences"=>{"Social Sciences"=>9}, "Decision Sciences"=>{"Decision Sciences"=>1}, "Psychology"=>{"Psychology"=>1}, "Immunology and Microbiology"=>{"Immunology and Microbiology"=>2}, "Economics, Econometrics and Finance"=>{"Economics, Econometrics and Finance"=>3}, "Agricultural and Biological Sciences"=>{"Agricultural and Biological Sciences"=>6}, "Computer Science"=>{"Computer Science"=>1}, "Nursing and Health Professions"=>{"Nursing and Health Professions"=>7}, "Business, Management and Accounting"=>{"Business, Management and Accounting"=>2}, "Unspecified"=>{"Unspecified"=>9}, "Veterinary Science and Veterinary Medicine"=>{"Veterinary Science and Veterinary Medicine"=>1}}, "reader_count_by_country"=>{"Canada"=>3, "Brazil"=>1, "France"=>1, "Spain"=>1}, "group_count"=>4}

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Figshare

  • {"files"=>["https://ndownloader.figshare.com/files/1268559"], "description"=>"<p>Decision tree.</p>", "links"=>[], "tags"=>[], "article_id"=>842039, "categories"=>["Biological Sciences", "Science Policy"], "users"=>["Andreas Kuznik", "Mohammed Lamorde", "Agnes Nyabigambo", "Yukari C. Manabe"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1001545.g001"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Decision_tree_/842039", "title"=>"Decision tree.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2013-11-05 03:00:44"}
  • {"files"=>["https://ndownloader.figshare.com/files/1268560"], "description"=>"<p>DR Congo, Democratic Republic of the Congo.</p>", "links"=>[], "tags"=>["icers"], "article_id"=>842040, "categories"=>["Biological Sciences", "Science Policy"], "users"=>["Andreas Kuznik", "Mohammed Lamorde", "Agnes Nyabigambo", "Yukari C. Manabe"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1001545.g002"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Country_ICERs_by_prevalence_/842040", "title"=>"Country ICERs by prevalence.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2013-11-05 03:00:44"}
  • {"files"=>["https://ndownloader.figshare.com/files/1268561"], "description"=>"a<p>Reference <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001545#pmed.1001545-Hawkes1\" target=\"_blank\">[25]</a> does not report a 95% CI for this end point. We approximated the 95% CI by calculating the weighted average of the lower and upper confidence ranges for the three last studies reported in Figure 4A of <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001545#pmed.1001545-Hawkes1\" target=\"_blank\">[25]</a> (page 689).</p>b<p>Reference <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001545#pmed.1001545-World1\" target=\"_blank\">[17]</a> suggests a range of 0%–6% for one-way sensitivity analyses, but does not report a suggested 95% confidence interval for PSAs.</p><p>RR, relative risk.</p>", "links"=>[], "tags"=>[], "article_id"=>842041, "categories"=>["Biological Sciences", "Science Policy"], "users"=>["Andreas Kuznik", "Mohammed Lamorde", "Agnes Nyabigambo", "Yukari C. Manabe"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1001545.t001"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_General_model_inputs_/842041", "title"=>"General model inputs.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-11-05 03:00:44"}
  • {"files"=>["https://ndownloader.figshare.com/files/1268562"], "description"=>"<p>Distribution in the PSAs is given in parentheses in the column heads.</p>a<p>The weighted average rate of 40.7% was used in cases where the proportion of women screened for syphilis infection in the antenatal care setting was not reported.</p>b<p>The syphilis prevalence estimate of 1.9% was reported in the 2002 HIV/AIDS surveillance update by the WHO <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001545#pmed.1001545-World4\" target=\"_blank\">[23]</a>. For this specific country, syphilis prevalence data from the antenatal care setting were not available, neither in one of the WHO reports nor in the scientific literature.</p>c<p>The 2002 HIV/AIDS surveillance report by the WHO <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001545#pmed.1001545-World4\" target=\"_blank\">[23]</a> reported a syphilis prevalence of 11% in the general female population; a study by Bertherat et al. <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001545#pmed.1001545-Bertherat1\" target=\"_blank\">[51]</a> reported 8.6%, also in the general female population; and a joint report by the WHO, Joint United Nations Programme on HIV/AIDS, and United Nations Children's Fund <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001545#pmed.1001545-World2\" target=\"_blank\">[19]</a> in the antenatal care setting reported 1%, although with a cautionary note that the data may not be nationally representative. Therefore, the lower of the two other estimates was used.</p>d<p>The syphilis prevalence estimate of 7.0% was reported in the 2002 HIV/AIDS surveillance update by the WHO <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001545#pmed.1001545-World4\" target=\"_blank\">[23]</a>. For this specific country, syphilis prevalence data from the antenatal care setting were not available, neither in one of the WHO reports nor in the scientific literature.</p>e<p>The syphilis prevalence estimate of 3.0% was reported in the 2007 HIV/AIDS surveillance update by the WHO <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001545#pmed.1001545-World5\" target=\"_blank\">[24]</a>. For this specific country, syphilis prevalence data from the antenatal care setting were not available, neither in one of the WHO reports nor in the scientific literature.</p>f<p>The 2002 HIV/AIDS surveillance report by the WHO <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001545#pmed.1001545-World4\" target=\"_blank\">[23]</a> reported a syphilis prevalence of 20.3% in the antenatal care setting, the 2007 HIV/AIDS surveillance report by the WHO <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001545#pmed.1001545-World5\" target=\"_blank\">[24]</a> reported 8.3% in the general female population, and a joint report by the WHO, Joint United Nations Programme on HIV/AIDS, and United Nations Children's Fund <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001545#pmed.1001545-World2\" target=\"_blank\">[19]</a> in the antenatal care setting reported 5.3%, although with a cautionary note that the data may not be nationally representative. Therefore, the lower of the two other estimates was used.</p>", "links"=>[], "tags"=>[], "article_id"=>842042, "categories"=>["Biological Sciences", "Science Policy"], "users"=>["Andreas Kuznik", "Mohammed Lamorde", "Agnes Nyabigambo", "Yukari C. Manabe"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1001545.t002"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Country_specific_model_inputs_/842042", "title"=>"Country-specific model inputs.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-11-05 03:00:44"}
  • {"files"=>["https://ndownloader.figshare.com/files/1268563"], "description"=>"a<p>We assumed that the proportion of women tested for syphilis in the antenatal care setting in the 20 African countries that do not report such data is equal to the weighted average (40.7%) of the 23 African countries that do report it. Should the current rate of syphilis screening turn out to be lower than 40.7% in these cases, the number of events and DALYs averted, as well as direct medical cost, would increase proportionately.</p>", "links"=>[], "tags"=>[], "article_id"=>842043, "categories"=>["Biological Sciences", "Science Policy"], "users"=>["Andreas Kuznik", "Mohammed Lamorde", "Agnes Nyabigambo", "Yukari C. Manabe"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1001545.t003"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Model_results_/842043", "title"=>"Model results.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-11-05 03:00:44"}
  • {"files"=>["https://ndownloader.figshare.com/files/1268564"], "description"=>"<p>All costs in US dollars. Incremental cost-effectiveness thresholds obtained in one-way sensitivity analyses were calculated by replacing the base case estimates of a single parameter in the model with a very high and a very low value, while leaving all other model parameters unchanged. For space considerations, <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001545#pmed-1001545-t004\" target=\"_blank\">Table 4</a> reports only the upper end of the new ICER range.</p>a<p>No 95% confidence interval was available for these parameters; we therefore used a subjective range for syphilis prevalence and nurse wages, and looked to cost estimates cited in other published sources to inform the sensitivity range for the ICS test and the cost of penicillin therapy.</p>b<p>The sensitivity range was informed by 95% confidence intervals around the base case estimate.</p>c<p>The sensitivity range of the discount rate followed WHO guidance <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001545#pmed.1001545-United1\" target=\"_blank\">[16]</a>.</p><p>RR, relative risk.</p>", "links"=>[], "tags"=>["daly"], "article_id"=>842044, "categories"=>["Biological Sciences", "Science Policy"], "users"=>["Andreas Kuznik", "Mohammed Lamorde", "Agnes Nyabigambo", "Yukari C. Manabe"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1001545.t004"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_One_way_sensitivity_analyses_8212_cost_per_DALY_averted_/842044", "title"=>"One-way sensitivity analyses—cost per DALY averted.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-11-05 03:00:44"}
  • {"files"=>["https://ndownloader.figshare.com/files/1268565", "https://ndownloader.figshare.com/files/1268566"], "description"=>"<div><p>Background</p><p>Untreated syphilis in pregnancy is associated with adverse clinical outcomes for the infant. Most syphilis infections occur in sub-Saharan Africa (SSA), where coverage of antenatal screening for syphilis is inadequate. Recently introduced point-of-care syphilis tests have high accuracy and demonstrate potential to increase coverage of antenatal screening. However, country-specific cost-effectiveness data for these tests are limited. The objective of this analysis was to evaluate the cost-effectiveness and budget impact of antenatal syphilis screening for 43 countries in SSA and estimate the impact of universal screening on stillbirths, neonatal deaths, congenital syphilis, and disability-adjusted life years (DALYs) averted.</p><p>Methods and Findings</p><p>The decision analytic model reflected the perspective of the national health care system and was based on the sensitivity (86%) and specificity (99%) reported for the immunochromatographic strip (ICS) test. Clinical outcomes of infants born to syphilis-infected mothers on the end points of stillbirth, neonatal death, and congenital syphilis were obtained from published sources. Treatment was assumed to consist of three injections of benzathine penicillin. Country-specific inputs included the antenatal prevalence of syphilis, annual number of live births, proportion of women with at least one antenatal care visit, per capita gross national income, and estimated hourly nurse wages. In all 43 sub-Saharan African countries analyzed, syphilis screening is highly cost-effective, with an average cost/DALY averted of US$11 (range: US$2–US$48). Screening remains highly cost-effective even if the average prevalence falls from the current rate of 3.1% (range: 0.6%–14.0%) to 0.038% (range: 0.002%–0.113%). Universal antenatal screening of pregnant women in clinics may reduce the annual number of stillbirths by up to 64,000, neonatal deaths by up to 25,000, and annual incidence of congenital syphilis by up to 32,000, and avert up to 2.6 million DALYs at an estimated annual direct medical cost of US$20.8 million.</p><p>Conclusions</p><p>Use of ICS tests for antenatal syphilis screening is highly cost-effective in SSA. Substantial reduction in DALYs can be achieved at a relatively modest budget impact. In SSA, antenatal programs should expand access to syphilis screening using the ICS test.</p><p><i>Please see later in the article for the Editors' Summary</i></p></div>", "links"=>[], "tags"=>["syphilis", "point-of-care", "sub-saharan", "african", "cost-effectiveness"], "article_id"=>842045, "categories"=>["Biological Sciences", "Science Policy"], "users"=>["Andreas Kuznik", "Mohammed Lamorde", "Agnes Nyabigambo", "Yukari C. Manabe"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1001545.s001", "https://dx.doi.org/10.1371/journal.pmed.1001545.s002"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Antenatal_Syphilis_Screening_Using_Point_of_Care_Testing_in_Sub_Saharan_African_Countries_A_Cost_Effectiveness_Analysis_/842045", "title"=>"Antenatal Syphilis Screening Using Point-of-Care Testing in Sub-Saharan African Countries: A Cost-Effectiveness Analysis", "pos_in_sequence"=>0, "defined_type"=>4, "published_date"=>"2013-11-05 03:00:44"}

PMC Usage Stats | Further Information

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Relative Metric

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