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Zulu EM, Herlihy JM, Duffy CR, Mwananyanda L, Chilengi R, Forman L, Heeren T, Gill CJ, Chavuma R, Payne-Lohman B, Thea DM. Single-test syphilis serology: A case of not seeing the forest for the trees. PLoS One 2024; 19:e0303253. [PMID: 38723103 PMCID: PMC11081208 DOI: 10.1371/journal.pone.0303253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
INTRODUCTION There have been few empirical studies for diagnostic test accuracy of syphilis using a sequence of rapid tests in populations with low prevalence of syphilis such as pregnant women. This analysis describes syphilis test positivity frequency among pregnant women at an antenatal clinic in Zambia using a reverse-sequence testing algorithm for antenatal syphilis screening. METHODS Between August 2019 and May 2023, we recruited 1510 pregnant women from a peri-urban hospital in Lusaka, Zambia. HIV positive and HIV negative women were enrolled in a 1:1 ratio. Blood collected at recruitment from the pregnant mothers was tested on-site for syphilis using a rapid treponemal test. Samples that tested positive were further tested at a different laboratory, with rapid plasma reagin using archived plasma. RESULTS Of the total 1,421 sera samples which were screened with a rapid treponemal test, 127 (8.9%) were positive and 1,294 (91.1%) were negative. Sufficient additional samples were available to perform RPR testing on 114 of the 127 (89.8%) RDT positive specimens. Thirty-one (27.2%) of these 114 were reactive by RPR and 83 (72.8%) were negative, resulting in a syphilis overtreatment rate of 3 fold (i.e, 84/114). Insufficient sample or test kit availability prevented any testing for the remaining 89 (5.9%) participants. CONCLUSION Use of only treponemal tests in low prevalence populations, like pregnant women, subjects individuals with non-active syphilis to the costs and possible risks of overtreatment. The use of the dual treponemal and non-treponemal tests would minimize this risk at some additional cost.
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Affiliation(s)
| | - Julie M. Herlihy
- Department of Pediatrics, Boston Medical Center, Boston University, Chobanian & Avedisian School of Medicine, Boston, Massachusetts, United States of America
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Cassandra R. Duffy
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Lawrence Mwananyanda
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Leah Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Tim Heeren
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Christopher J. Gill
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | | | - Barbara Payne-Lohman
- Institute for Immunology and Informatics, University of Rhode Island, Kingston, Rhode Island, United States of America
| | - Donald M. Thea
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
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Zhang M, Zhang H, Hui X, Qu H, Xia J, Xu F, Shi C, He J, Cao Y, Hu M. The cost-effectiveness of syphilis screening in pregnant women: a systematic literature review. Front Public Health 2024; 12:1268653. [PMID: 38577277 PMCID: PMC10993388 DOI: 10.3389/fpubh.2024.1268653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 02/23/2024] [Indexed: 04/06/2024] Open
Abstract
Introduction The cost-effectiveness study of syphilis screening in pregnant women has not been synthesized. This study aimed to synthesize the economic evidence on the cost-effectiveness of syphilis screening in pregnant women that might contribute to making recommendations on the future direction of syphilis screening approaches. Methods We systematically searched MEDLINE, PubMed, and Web of Science databases for relevant studies published before 19 January 2023 and identified the cost-effectiveness analyses for syphilis screening in pregnant women. The methodological design quality was appraised by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist. Results In total, 17 literature met the eligibility criteria for a full review. Of the 17 studies, four evaluated interventions using different screening methods, seven assessed a combination of syphilis testing and treatment interventions, three focused on repeat screening intervention, and four evaluated the interventions that integrated syphilis and HIV testing. The most cost-effective strategy appeared to be rapid syphilis testing with high treatment rates in pregnant women who were positive. Discussion The cost-effectiveness of syphilis screening for pregnancy has been widely demonstrated. It is very essential to improve the compliance with maternal screening and the treatment rates for positive pregnant women while implementing screening.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Mengcai Hu
- Department of Health Care, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Miao P, Terris-Prestholt F, Fairley CK, Tucker JD, Wiseman V, Mayaud P, Zhang Y, Rowley J, Gottlieb S, Korenromp EL, Watts CG, Ong JJ. Ignored and undervalued in public health: a systematic review of health state utility values associated with syphilis infection. Health Qual Life Outcomes 2024; 22:17. [PMID: 38350925 PMCID: PMC10863090 DOI: 10.1186/s12955-024-02234-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/29/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Syphilis is a sexually transmitted infection causing significant global morbidity and mortality. To inform policymaking and economic evaluation studies for syphilis, we summarised utility and disability weights for health states associated with syphilis. METHODS We conducted a systematic review, searching six databases for economic evaluations and primary valuation studies related to syphilis from January 2000 to February 2022. We extracted health state utility values or disability weights, including identification of how these were derived. The study was registered in the international prospective register of systematic reviews (PROSPERO, CRD42021230035). FINDINGS Of 3401 studies screened, 22 economic evaluations, two primary studies providing condition-specific measures, and 13 burden of disease studies were included. Fifteen economic evaluations reported outcomes as disability-adjusted life years (DALYs) and seven reported quality-adjusted life years (QALYs). Fourteen of 15 economic evaluations that used DALYS based their values on the original Global Burden of Disease (GBD) study from 1990 (published in 1996). For the seven QALY-related economic evaluations, the methodology varied between studies, with some studies using assumptions and others creating utility weights or converting them from disability weights. INTERPRETATION We found a limited evidence base for the valuation of health states for syphilis, a lack of transparency for the development of existing health state utility values, and inconsistencies in the application of these values to estimate DALYs and QALYs. Further research is required to expand the evidence base so that policymakers can access accurate and well-informed economic evaluations to allocate resources to address syphilis and implement syphilis programs that are cost-effective.
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Affiliation(s)
- Patrick Miao
- Central Clinical School, Monash University, Melbourne, Australia
- Melbourne Sexual Health Centre, 580 Swanston Street, Carlton, Victoria, 3053, Australia
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- UNAIDS, Geneva, Switzerland
| | - Christopher K Fairley
- Central Clinical School, Monash University, Melbourne, Australia
- Melbourne Sexual Health Centre, Melbourne, Australia
| | - Joseph D Tucker
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Philippe Mayaud
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ying Zhang
- Central Clinical School, Monash University, Melbourne, Australia
| | - Jane Rowley
- Global HIV, Hepatitis and Sexual Transmitted Infections Programme, World Health Organization, Geneva, Switzerland
| | - Sami Gottlieb
- Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | | | - Caroline G Watts
- Kirby Institute, University of New South Wales, Sydney, Australia
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, Australia
| | - Jason J Ong
- Central Clinical School, Monash University, Melbourne, Australia.
- Melbourne Sexual Health Centre, Melbourne, Australia.
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Ramchandani MS, Cannon CA, Marra CM. Syphilis. Infect Dis Clin North Am 2023; 37:195-222. [PMID: 37005164 DOI: 10.1016/j.idc.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
Syphilis is an important public health problem in the U.S. and many high-income nations. The rates of syphilis continue to increase and there is an urgent need for medical providers of a variety of backgrounds to recognize this disease. In this review, we cover the key clinical findings of syphilis and provide an overview of the diagnosis and management of this disease in adults.
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Batura N, Saweri OP, Vallely A, Pomat W, Homer C, Guy R, Luchters S, Mola G, Vallely LM, Morgan C, Kariwiga G, Wand H, Rogerson S, Tabrizi SN, Whiley DM, Low N, Peeling RW, Siba PM, Riddell M, Laman M, Bolnga J, Robinson LJ, Morewaya J, Badman S, Kelly-Hanku A, Toliman PJ, Peter W, Peach E, Garland S, Kaldor J, Wiseman V. Point-of-care testing and treatment of sexually transmitted and genital infections during pregnancy in Papua New Guinea (WANTAIM trial): protocol for an economic evaluation alongside a cluster-randomised trial. BMJ Open 2021; 11:e046308. [PMID: 34385236 PMCID: PMC8362726 DOI: 10.1136/bmjopen-2020-046308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 07/09/2021] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Left untreated, sexually transmitted and genital infections (henceforth STIs) in pregnancy can lead to serious adverse outcomes for mother and child. Papua New Guinea (PNG) has among the highest prevalence of curable STIs including syphilis, chlamydia, gonorrhoea, trichomoniasis and bacterial vaginosis, and high neonatal mortality rates. Diagnosis and treatment of these STIs in PNG rely on syndromic management. Advances in STI diagnostics through point-of-care (PoC) testing using GeneXpert technology hold promise for resource-constrained countries such as PNG. This paper describes the planned economic evaluation of a cluster-randomised cross-over trial comparing antenatal PoC testing and immediate treatment of curable STIs with standard antenatal care in two provinces in PNG. METHODS AND ANALYSIS Cost-effectiveness of the PoC intervention compared with standard antenatal care will be assessed prospectively over the trial period (2017-2021) from societal and provider perspectives. Incremental cost-effectiveness ratios will be calculated for the primary health outcome, a composite measure of the proportion of either preterm birth and/or low birth weight; for life years saved; for disability-adjusted life years averted; and for non-health benefits (financial risk protection and improved health equity). Scenario analyses will be conducted to identify scale-up options, and budget impact analysis will be undertaken to understand short-term financial impacts of intervention adoption on the national budget. Deterministic and probabilistic sensitivity analysis will be conducted to account for uncertainty in key model inputs. ETHICS AND DISSEMINATION This study has ethical approval from the Institutional Review Board of the PNG Institute of Medical Research; the Medical Research Advisory Committee of the PNG National Department of Health; the Human Research Ethics Committee of the University of New South Wales; and the Research Ethics Committee of the London School of Hygiene and Tropical Medicine. Findings will be disseminated through national stakeholder meetings, conferences, peer-reviewed publications and policy briefs. TRIAL REGISTRATION NUMBER ISRCTN37134032.
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Affiliation(s)
- Neha Batura
- Institute for Global Health, University College London, London, UK
| | - Olga Pm Saweri
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Andrew Vallely
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - William Pomat
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Caroline Homer
- The Burnet Institute, Melbourne, Victoria, Australia
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Rebecca Guy
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Stanley Luchters
- The Burnet Institute, Melbourne, Victoria, Australia
- Department of Public Health and Preventive Medicine, Ghent University, Ghent, Belgium
- Department of Population Health, Medical College, Aga Khan University, Nairobi, Kenya
- Department of Epidemiology and Preventive Medicine, Monash University, Monash, Victoria, Australia
| | - Glen Mola
- School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - Lisa M Vallely
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | | | - Grace Kariwiga
- Milne Bay Provincial Health Authority, Alotau, Papua New Guinea
| | - Handan Wand
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen Rogerson
- Department of Medicine, The Doherty Institute, University of Melbourne, Melbourne, Victoria, Australia
| | | | - David M Whiley
- The University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Rosanna W Peeling
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter M Siba
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Michaela Riddell
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Moses Laman
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - John Bolnga
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Leanne J Robinson
- The Burnet Institute, Melbourne, Victoria, Australia
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Jacob Morewaya
- Milne Bay Provincial Health Authority, Alotau, Papua New Guinea
| | - Steven Badman
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Angela Kelly-Hanku
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Pamela J Toliman
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Wilfred Peter
- Madang Provincial Health Authority, Madang, Papua New Guinea
| | | | - Suzanne Garland
- Microbiology and Infectious Diseases Department, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - John Kaldor
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Virginia Wiseman
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Saweri OPM, Batura N, Al Adawiyah R, Causer LM, Pomat WS, Vallely AJ, Wiseman V. Economic evaluation of point-of-care testing and treatment for sexually transmitted and genital infections in pregnancy in low- and middle-income countries: A systematic review. PLoS One 2021; 16:e0253135. [PMID: 34138932 PMCID: PMC8211269 DOI: 10.1371/journal.pone.0253135] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 05/30/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Sexually transmitted and genital infections in pregnancy are associated with adverse pregnancy and birth outcomes. Point-of-care tests for these infections facilitate testing and treatment in a single antenatal clinic visit and may reduce the risk of adverse outcomes. Successful implementation and scale-up depends on understanding comparative effectiveness of such programmes and their comparative costs and cost effectiveness. This systematic review synthesises and appraises evidence from economic evaluations of point-of-care testing and treatment for sexually transmitted and genital infections among pregnant women in low- and middle-income countries. METHODS Medline, Embase and Web of Science databases were comprehensively searched using pre-determined criteria. Additional literature was identified by searching Google Scholar and the bibliographies of all included studies. Economic evaluations were eligible if they were set in low- and middle-income countries and assessed antenatal point-of-care testing and treatment for syphilis, chlamydia, gonorrhoea, trichomoniasis, and/or bacterial vaginosis. Studies were analysed using narrative synthesis. Methodological and reporting standards were assessed using two published checklists. RESULTS Sixteen economic evaluations were included in this review; ten based in Africa, three in Latin and South America and three were cross-continent comparisons. Fifteen studies assessed point-of-care testing and treatment for syphilis, while one evaluated chlamydia. Key drivers of cost and cost-effectiveness included disease prevalence; test, treatment, and staff costs; test sensitivity and specificity; and screening and treatment coverage. All studies met 75% or more of the criteria of the Drummond Checklist and 60% of the Consolidated Health Economics Evaluation Reporting Standards. CONCLUSIONS Generally, point-of-care testing and treatment was cost-effective compared to no screening, syndromic management, and laboratory-based testing. Future economic evaluations should consider other common infections, and their lifetime impact on mothers and babies. Complementary affordability and equity analyses would strengthen the case for greater investment in antenatal point-of-care testing and treatment for sexually transmitted and genital infections.
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Affiliation(s)
- Olga P. M. Saweri
- The Kirby Institute, University of New South Wales, Sydney, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
- * E-mail:
| | - Neha Batura
- University College London, London, United Kingdom
| | | | - Louise M. Causer
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - William S. Pomat
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Andrew J. Vallely
- The Kirby Institute, University of New South Wales, Sydney, Australia
- The Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea
| | - Virginia Wiseman
- The Kirby Institute, University of New South Wales, Sydney, Australia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Maan I, Lawrence DS, Tlhako N, Ramontshonyana K, Mussa A, Wynn A, Marks M, Ramogola-Masire D, Morroni C. Using a dual antibody point-of-care test with visual and digital reads to diagnose syphilis among people living with HIV in Botswana. Int J STD AIDS 2021; 32:453-461. [PMID: 33570464 PMCID: PMC8008391 DOI: 10.1177/0956462420975639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 10/30/2020] [Indexed: 11/16/2022]
Abstract
Syphilis data from low- and middle-income countries are lacking due to limited testing. Point-of-care tests (POCTs) have been promoted to expand testing but previously only included treponemal tests, which cannot distinguish active from past infection. We aimed to assess the feasibility of using a combined treponemal and non-treponemal POCT in HIV clinic patients in Gaborone, Botswana, and estimate syphilis prevalence in our clinic sample using this approach. We recruited 390 non-pregnant patients. Participants underwent a combined treponemal and non-treponemal POCT (Dual Path Platform (DPP®) Syphilis Screen and Confirm Assay (Chembio Diagnostic Systems)) on finger-prick blood sample and a questionnaire. Median age 45 years, 30% men, median CD4 count 565 cells/μL, and 91% had an HIV viral load <400 copies/mL. Five participants had active syphilis (1.3%, 95% CI 0.5-3.0%) and 64 had previous syphilis (16.4%, 95% CI 13.0-20.4%) using the DPP POCT. There was a reasonable level of agreement between digital and visual reading of the POCT (kappa statistic of 0.81); however, visual reading missed three active infections (60%). The level of active syphilis was similar to local antenatal data. The DPP POCT led to five participants with active syphilis being diagnosed and starting same-day treatment. The digital reader should be used.
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Affiliation(s)
- Irfaan Maan
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - David S Lawrence
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Nametso Tlhako
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Kehumile Ramontshonyana
- institution-id-type="Ringgold" />Botswana University of Pennsylvania Partnership, Gaborone, Botswana
| | - Aamirah Mussa
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Adriane Wynn
- Division of Infectious Diseases & Global Public Health, University of California, San Diego, USA
| | - Michael Marks
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- institution-id-type="Ringgold" />Hospital for Tropical Diseases, London, UK
| | | | - Chelsea Morroni
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- institution-id-type="Ringgold" />Botswana University of Pennsylvania Partnership, Gaborone, Botswana
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
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Romero CP, Marinho DS, Castro R, de Aguiar Pereira CC, Silva E, Caetano R, Silva Elias FT, Chilcott J, Dixon S. Cost-Effectiveness Analysis of Point-of-Care Rapid Testing Versus Laboratory-Based Testing for Antenatal Screening of Syphilis in Brazil. Value Health Reg Issues 2020; 23:61-69. [PMID: 32841902 DOI: 10.1016/j.vhri.2020.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 12/27/2019] [Accepted: 03/25/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Severe consequences of mother-to-child transmission of syphilis and high increasing incidence of congenital syphilis remains an important public health problem in Brazil. Our objective was to assess the cost-effectiveness of a rapid point-of-care test (RT) and treatment of positive mothers immediately compared with a laboratory-based standard test (ST) with treatment at next follow-up visit. METHODS A decision analytic model was developed to estimate the incremental cost-effectiveness ratio (ICER) between antenatal syphilis screening strategies. The model was built with lifetime horizon from Brazilian health system perspective using 3% and 5% discount rates. A hypothetical cohort of pregnant women at reproductive age were used in the model. Health outcomes: low birth weight, stillbirths, neonatal deaths and congenital syphilis were estimated in disability-adjusted life-years (DALYs) lost. Microcosting study and secondary data provided parameters of direct medical costs. Probabilistic sensitivity analysis was undertaken. RESULTS For base case, the mean cost per pregnant woman screened was $2.63 (RT) and $2.48 (ST), respectively. Maternal syphilis was associated with a loss of 0.0043 DALYs (RT) and 0.0048 DALYs (ST) per mother screened. Expected value of incremental cost per DALY averted was $298.08. After 10 000 probabilistic sensitivity analysis model runs, incremental cost and health benefits were $0.15 (95% credible interval -1.56 to 1.92) and 0.00042 DALYs (95% credible interval -0.0036 to 0.0044), respectively, with a mean ICER of $357.44 per DALY. Screening with RT has a 58% chance of being the optimal strategy at a threshold of $3,200 per DALY. CONCLUSIONS In Brazil, antenatal screening with syphilis RT and immediate treatment is likely to be cost-effective compared with standard screening and must be prioritized in local settings.
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Affiliation(s)
- Carmen Phang Romero
- Centro de Desenvolvimento Tecnológico em Saúde, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil; Instituto Nacional de Ciência e Tecnologia de Inovação em Doenças de Populações Negligenciadas do Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brazil.
| | - Daniel S Marinho
- Centro de Desenvolvimento Tecnológico em Saúde, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil; Instituto Nacional de Ciência e Tecnologia de Inovação em Doenças de Populações Negligenciadas do Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brazil
| | - Rodolfo Castro
- Instituto Nacional de Ciência e Tecnologia de Inovação em Doenças de Populações Negligenciadas do Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brazil; Instituto de Saúde Coletiva, Universidade Federal do Estado do Rio de Janeiro, Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Claudia Cristina de Aguiar Pereira
- Instituto Nacional de Ciência e Tecnologia de Inovação em Doenças de Populações Negligenciadas do Conselho Nacional de Desenvolvimento Científico e Tecnológico, Brazil; Escola Nacional de Saúde Pública "Sérgio Arouca," Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | | | | | - James Chilcott
- School of Health and Related Research, University of Sheffield, Sheffield, England, UK
| | - Simon Dixon
- School of Health and Related Research, University of Sheffield, Sheffield, England, UK
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Toward Improving Accessibility of Point-of-Care Diagnostic Services for Maternal and Child Health in Low- and Middle-Income Countries. POINT OF CARE 2019; 18:17-25. [PMID: 30886544 PMCID: PMC6407818 DOI: 10.1097/poc.0000000000000180] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Point-of-care (POC) testing can improve health care provision in settings with limited access to health care services. Access to POC diagnostic services has shown potential to alleviate some diagnostic challenges and delays associated with laboratory-based methods in low- and middle-income countries. Improving accessibility to POC testing (POCT) services during antenatal and perinatal care is among the global health priorities to improve maternal and child health. This review provides insights on the availability of POC testing designed for diagnosing HIV, syphilis, and malaria in pregnancy to improve maternal and child health. In addition, factors such as accessibility of POC testing, training of health work force, and the efficiency of POC testing services delivery in low- and middle-income countries are discussed. A framework to help increase access to POC diagnostic services and improve maternal and child health outcomes in low- and middle-income countries is proposed.
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Comparison of RPR and ELISA with TPHA for the Diagnosis of Syphilis: Implication for Updating Syphilis Point-of-Care Tests in Ethiopia. J Immunol Res 2018; 2018:2978419. [PMID: 30069486 PMCID: PMC6057341 DOI: 10.1155/2018/2978419] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/24/2018] [Accepted: 05/27/2018] [Indexed: 11/24/2022] Open
Abstract
Background Syphilis is a sexually transmitted disease (STD) caused by the spirochete Treponema pallidum, and it persists to be a major public health problem in Africa, including Ethiopia. Syphilis diagnosis is made by either nontreponemal or treponemal approaches, though in developing countries the diagnosis relies mostly on nonspecific tests due to several reasons. Thus, the objective of this study was to assess the sensitivity, specificity, predictive values, and agreement of rapid plasma reagin (RPR) and enzyme-linked immunosorbent assay (ELISA) with Treponema pallidum hemagglutination assay (TPHA) as a gold standard for the diagnosis of syphilis. Results The sensitivity, specificity, and positive and negative predictive values of ECOTEST-RPR were 100%, 80.8%, 76.2%, and 100%, respectively. However, the sensitivity, specificity, and positive and negative predictive values of DIALAB-ELISA were 98.4%, 94.9%, 92.3%, and 98.9%, respectively. The agreement between DIALAB-ELISA and Randox-TPHA was excellent (kappa value: 0.96) as compared to ECOTEST-RPR and Randox-TPHA assay (kappa value: 0.88). Conclusion We found a characteristically variable performance of DIALAB-ELISA test and the currently available traditional ECOTEST-RPR test in the study area. The use of ECOTEST-RPR as a diagnostic test is confronted by its false positivity. Thus, neither the ECOTEST-RPR nor the DIALAB-ELISA test stands on its own to be used either as screening or confirmatory test for syphilis diagnosis. Consequently, thorough studies should be conducted aiming on a change of the current diagnostic scheme in the community.
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Marks M, Esau T, Asugeni R, Harrington R, Diau J, Toloka H, Asugeni J, Ansbro E, Solomon AW, Maclaren D, Redman-Maclaren M, Mabey DCW. Point-of-care tests for syphilis and yaws in a low-income setting - A qualitative study of healthcare worker and patient experiences. PLoS Negl Trop Dis 2018; 12:e0006360. [PMID: 29672524 PMCID: PMC5908063 DOI: 10.1371/journal.pntd.0006360] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 03/02/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction The human treponematoses comprise venereal syphilis and the three non-venereal or endemic treponematoses yaws, bejel, and pinta. Serological assays remain the most common diagnostic method for all treponemal infections. Point-of-care tests (POCTs) for syphilis and yaws allow testing without further development of infrastructure in populations where routine laboratory facilities are not available. Alongside the test’s performance characteristics assessed through diagnostic evaluation, it is important to consider broader issues when rolling out a POCT. Experience with malaria POCT roll-out in sub-Saharan Africa has demonstrated that both healthcare worker and patient beliefs may play a major role in shaping the real-world use of POCTs. We conducted a qualitative study evaluating healthcare worker and patient perceptions of using a syphilis/yaws POCT in clinics in the East Malaita region of Malaita province in the Solomon Islands. Prior to the study serology was only routinely available at the local district hospital. Methods The POCT was deployed in the outpatient and ante-natal departments of a district hospital and four rural health clinics served by the hospital. Each site was provided with training and an SOP on the performance, interpretation and recording of results. Treatment for those testing positive was provided, in line with Solomon Islands Ministry of Health and Medical Services’ guidelines for syphilis and yaws respectively. Alongside the implementation of the POCT we facilitated semi-structured interviews with both nurses and patients to explore individuals’ experiences and beliefs in relation to use of the POCT. Results and discussion Four main themes emerged in the interviews: 1) training and ease of performing the test; 2) time taken and ability to fit the test into a clinical workflow; 3) perceived reliability and trustworthiness of the test; and 4) level of the health care system the test was most usefully deployed. Many healthcare workers related their experience with the POCT to their experience using similar tests for malaria. Although the test was considered to take a relatively long time to perform the benefits of improved access to testing were considered positive by most healthcare workers. Qualitative data is needed to help inform better training packages to support the implementation of POCT in low-resource settings. Syphilis and yaws are closely related bacterial infections. In many countries where the diseases are found there is limited access to diagnostic testing. Recently a point of care test for both diseases has been developed. In the current study we evaluated the experience of healthcare workers and patients in using the test in the Solomon Islands. Both healthcare workers and patients valued the improved access to testing that provided by the point of care test. Experience of healthcare workers in using similar tests for other diseases, such as malaria, had both positive and negative impacts on their beliefs about the syphilis and yaws test.
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Affiliation(s)
- Michael Marks
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, United Kingdom
- Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, United Kingdom
- * E-mail:
| | - Tommy Esau
- Atoifi Adventist Hospital, Atoifi, Malaita Province, Solomon Islands
| | - Rowena Asugeni
- Atoifi Adventist Hospital, Atoifi, Malaita Province, Solomon Islands
| | - Relmah Harrington
- Atoifi Adventist Hospital, Atoifi, Malaita Province, Solomon Islands
| | - Jason Diau
- Atoifi Adventist Hospital, Atoifi, Malaita Province, Solomon Islands
| | - Hilary Toloka
- Atoifi Adventist Hospital, Atoifi, Malaita Province, Solomon Islands
| | - James Asugeni
- Atoifi Adventist Hospital, Atoifi, Malaita Province, Solomon Islands
| | - Eimhin Ansbro
- Department of Noncommunicable Disease Epidemiology, Faculty of Epidemiology and Public Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Anthony W. Solomon
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, United Kingdom
- Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, United Kingdom
| | - David Maclaren
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | | | - David C. W. Mabey
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, United Kingdom
- Hospital for Tropical Diseases, University College London Hospitals NHS Trust, London, United Kingdom
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Akhtar F, Rehman S. Prevention of Congenital Syphilis Through Antenatal Screenings in Lusaka, Zambia: A Systematic Review. Cureus 2018; 10:e2078. [PMID: 29560291 PMCID: PMC5856412 DOI: 10.7759/cureus.2078] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Congenital syphilis is one of the preventable diseases caused by the gram-negative bacteria Treponema pallidum; yet, it imposes a serious global health and economic burden, with more than half of the cases resulting in serious adverse outcomes, including infant mortality. Mother-to-child transmission (MTCT) of syphilis is estimated at 3.6 million adjusted life years (DALYs) and around $309 million in medical costs. In 2006, an estimated 9.7 million children of age less than five years died in developing countries; almost four million were neonatal deaths. There were 3.2 million stillbirths globally, among whom 95% were in the developing countries. In sub-Saharan Africa, there is an estimated 2.7% (0.1%-10.3%) of pregnant women infected with syphilis, representing more than 900,000 pregnancies at risk each year. There were many non-specific and specific diagnostic tests used in the past, which required laboratory equipment and electricity, but there are many newer tests available now that provide rapid results with high sensitivity and specificity, e.g., the immunochromatographic strip (ICS) and rapid syphilis tests (RST). Early syphilis can be completely eliminated with a single injection of penicillin, which is readily available, cheap, and highly effective, and treating pregnant women with penicillin is 98% effective at preventing congenital syphilis. Targeting women at a high risk of having syphilis makes universal screening in antenatal programs the most efficacious way to prevent syphilis-associated morbidity and mortality. The potential for a program to prevent congenital syphilis in the perinatal, neonatal, and postnatal periods is evident. While considering resource allocation to child survival programs in areas where the prevalence of syphilis is high, officials need to include antenatal syphilis screening, using rapid tests and treatment at the first contact of the mother with the health care system. In countries like Zambia and other resource-limited settings, a same-day test and treatment with penicillin should be prioritized to achieve the goal of eliminating congenital syphilis. Eliminating MTCT of syphilis through screening and treatment in antenatal care (ANC) is highly cost-effective in a wide range of settings, especially in countries with a high prevalence.
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Fitzpatrick C, Asiedu K, Sands A, Gonzalez Pena T, Marks M, Mitja O, Meheus F, Van der Stuyft P. The cost and cost-effectiveness of rapid testing strategies for yaws diagnosis and surveillance. PLoS Negl Trop Dis 2017; 11:e0005985. [PMID: 29073145 PMCID: PMC5658197 DOI: 10.1371/journal.pntd.0005985] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 09/21/2017] [Indexed: 11/29/2022] Open
Abstract
Background Yaws is a non-venereal treponemal infection caused by Treponema pallidum subspecies pertenue. The disease is targeted by WHO for eradication by 2020. Rapid diagnostic tests (RDTs) are envisaged for confirmation of clinical cases during treatment campaigns and for certification of the interruption of transmission. Yaws testing requires both treponemal (trep) and non-treponemal (non-trep) assays for diagnosis of current infection. We evaluate a sequential testing strategy (using a treponemal RDT before a trep/non-trep RDT) in terms of cost and cost-effectiveness, relative to a single-assay combined testing strategy (using the trep/non-trep RDT alone), for two use cases: individual diagnosis and community surveillance. Methods We use cohort decision analysis to examine the diagnostic and cost outcomes. We estimate cost and cost-effectiveness of the alternative testing strategies at different levels of prevalence of past/current infection and current infection under each use case. We take the perspective of the global yaws eradication programme. We calculate the total number of correct diagnoses for each strategy over a range of plausible prevalences. We employ probabilistic sensitivity analysis (PSA) to account for uncertainty and report 95% intervals. Results At current prices of the treponemal and trep/non-trep RDTs, the sequential strategy is cost-saving for individual diagnosis at prevalence of past/current infection less than 85% (81–90); it is cost-saving for surveillance at less than 100%. The threshold price of the trep/non-trep RDT (below which the sequential strategy would no longer be cost-saving) is US$ 1.08 (1.02–1.14) for individual diagnosis at high prevalence of past/current infection (51%) and US$ 0.54 (0.52–0.56) for community surveillance at low prevalence (15%). Discussion We find that the sequential strategy is cost-saving for both diagnosis and surveillance in most relevant settings. In the absence of evidence assessing relative performance (sensitivity and specificity), cost-effectiveness is uncertain. However, the conditions under which the combined test only strategy might be more cost-effective than the sequential strategy are limited. A cheaper trep/non-trep RDT is needed, costing no more than US$ 0.50–1.00, depending on the use case. Our results will help enhance the cost-effectiveness of yaws programmes in the 13 countries known to be currently endemic. It will also inform efforts in the much larger group of 71 countries with a history of yaws, many of which will have to undertake surveillance to confirm the interruption of transmission. Yaws is a non-venereal treponemal infection. The disease is targeted by WHO for eradication by 2020. Testing is envisaged for diagnosis to confirm of clinical cases during treatment campaigns and for surveillance to certify the interruption of transmission. However resources available to the global eradication programme are severely limited and the cost of testing must be contained. Testing requires simultaneous detection of antibodies to both treponemal and non-treponemal antigens for diagnosis of active infection. Currently, there is one commercially available rapid diagnostic test for yaws that can do just that. However, it is considerably more expensive than the available syphilis tests detecting treponemal antibodies only. We evaluate the cost and cost-effectiveness of a sequential testing strategy (using the treponemal test first, before the combined test), relative to a combined testing strategy (using only the combined test). We consider the two use cases: individual diagnosis and community surveillance. We find that the sequential strategy is cost-saving for both diagnosis and surveillance in most relevant settings. Yaws eradication programme should consider adopting the sequential strategy. Still, a cheaper trep/non-trep RDT is needed, costing no more than US$ 0.50–1.00. Our results will help enhance the cost-effectiveness of yaws programmes in the 13 countries known to be currently endemic. It will also inform efforts in the much larger group of 71 countries with a history of yaws, many of which will have to undertake surveillance to confirm the interruption of transmission.
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Affiliation(s)
- Christopher Fitzpatrick
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
- * E-mail:
| | - Kingsley Asiedu
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Anita Sands
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
| | - Tita Gonzalez Pena
- Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
- Department of Chemistry, University of North Carolina at Chapel Hill, Chapel Hill, United States of America
| | - Michael Marks
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Oriol Mitja
- Barcelona Institute for Global Health, Hospital Clinic -University of Barcelona, Barcelona, Spain
| | - Filip Meheus
- Unit of Epidemiology and Control of Neglected Tropical Diseases, Institute of Tropical Medicine, Antwerp, Belgium
- Prevention and Implementation Group, International Agency for Research on Cancer, Lyon, France
| | - Patrick Van der Stuyft
- Unit of General Epidemiology and Disease Control, Institute of Tropical Medicine, Antwerp, Belgium
- Department of Public Health, Ghent University, Ghent, Belgium
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Unemo M, Bradshaw CS, Hocking JS, de Vries HJC, Francis SC, Mabey D, Marrazzo JM, Sonder GJB, Schwebke JR, Hoornenborg E, Peeling RW, Philip SS, Low N, Fairley CK. Sexually transmitted infections: challenges ahead. THE LANCET. INFECTIOUS DISEASES 2017; 17:e235-e279. [PMID: 28701272 DOI: 10.1016/s1473-3099(17)30310-9] [Citation(s) in RCA: 447] [Impact Index Per Article: 63.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 03/13/2017] [Accepted: 03/30/2017] [Indexed: 12/30/2022]
Abstract
WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research. In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control. Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease. The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials. Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches. STIs disproportionately affect low-income and middle-income countries. We review strategies for case management, focusing on point-of-care tests that hold considerable potential for improving STI control. Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation. Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health.
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Affiliation(s)
- Magnus Unemo
- WHO Collaborating Centre for Gonorrhoea and Other Sexually Transmitted Infections, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Catriona S Bradshaw
- Central Clinical School, Monash University, Melbourne, VIC, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
| | - Jane S Hocking
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Henry J C de Vries
- STI Outpatient Clinic, Public Health Service of Amsterdam, Amsterdam, Netherlands; Amsterdam Institute for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; Department of Dermatology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Suzanna C Francis
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - David Mabey
- Clinical Research Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Jeanne M Marrazzo
- Department of Medicine, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Gerard J B Sonder
- Department of Infectious Diseases, Public Health Service of Amsterdam, Amsterdam, Netherlands; Division of Infectious Diseases, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jane R Schwebke
- Department of Medicine, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Elske Hoornenborg
- STI Outpatient Clinic, Public Health Service of Amsterdam, Amsterdam, Netherlands
| | - Rosanna W Peeling
- Clinical Research Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Susan S Philip
- Disease Prevention and Control Population Health Division, San Francisco Department of Public Health, San Francisco, CA, USA
| | - Nicola Low
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Christopher K Fairley
- Central Clinical School, Monash University, Melbourne, VIC, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia.
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Introducing onsite antenatal syphilis screening in Burkina Faso: implementation and evaluation of a feasibility intervention tailored to a local context. BMC Health Serv Res 2017; 17:378. [PMID: 28558812 PMCID: PMC5450306 DOI: 10.1186/s12913-017-2325-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 05/19/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although the advantages of introducing point of care testing for syphilis in antenatal care (ANC) are well documented, there is little evidence on how to address structural issues within health systems. A better understanding of how these interventions work in a range of settings and contexts is needed in order to overcome bottlenecks at health system level. To better understand the relationships between implementation and context we developed and implemented an intervention focused on integrating a rapid screening test for syphilis in ANC services in rural primary health care facilities in Burkina Faso. This manuscript describes the intervention and reports on feasibility and acceptability of the intervention, the facilitators and barriers to the implementation of this intervention and the likelihood that point of care test for syphilis will become routinely incorporated in practice. METHODS In Kaya Health and Demographic Surveillance System (Kaya HDSS), all 7 primary healthcare facilities were selected for intervention in 2013. A participatory approach was used to design and implement an antenatal syphilis screening intervention. The Normalization Process Model (NPM) proposed by May et al. was adapted in order to identify barriers and facilitators and to explore the likelihood to become routinely incorporated in practice. Registers, Observations (n = 14 ANC 1) of interactions between patients and health workers during ANC and interviews with health workers (n = 14) were our data sources. RESULTS An intervention that included onsite training, provision of supplies and medicines, quality control and supervision was implemented in 7 health facilities in 2013. Rapid syphilis test and treatment were delivered during ANC within the examination room with no specific additional mechanism regarding staff organization. The perceived barriers were lack of training of all staff, workload, stock-outs of consumables and lack of motivation of staff. Key facilitators included political environment, ease of use of test and acceptability to pregnant women. CONCLUSIONS Onsite testing for antenatal syphilis is a feasible and acceptable intervention in ANC at primary health facility in Burkina Faso. The point-of care test for syphilis is more likely to be acceptable by health workers as routine service and incorporated as a normal practice. TRIAL REGISTRATION The study was retrospectively registered on ClinicalTrials.gov under the Trial Registration Number NCT03156751 .
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Obure CD, Gaitan-Duarte H, Losada Saenz R, Gonzalez L, Angel-Muller E, Laverty M, Perez F. A comparative analysis of costs of single and dual rapid HIV and syphilis diagnostics: results from a randomised controlled trial in Colombia. Sex Transm Infect 2017; 93:482-486. [PMID: 28495681 PMCID: PMC5739853 DOI: 10.1136/sextrans-2016-052961] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 03/28/2017] [Accepted: 04/18/2017] [Indexed: 11/15/2022] Open
Abstract
Background HIV and congenital syphilis are major public health burdens contributing to substantial perinatal morbidity and mortality globally. Although studies have reported on the costs and cost-effectiveness of rapid diagnostic tests (RDTs) for syphilis screening within antenatal care in a number of resource-constrained settings, empirical evidence on country-specific cost and estimates of single RDTs compared with dual RDTs for HIV and syphilis are limited. Methods A cluster randomised controlled study design was used to compare the incremental costs of two testing algorithms: (1) single RDTs for HIV and syphilis and (2) dual RDTs for HIV and syphilis, in 12 health facilities in Bogota and Cali, Colombia. The costs of single HIV and syphilis RDTs and dual HIV and syphilis RDTs were collected from each of the health facilities. The economic costs per woman tested for HIV and syphilis and costs per woman treated for syphilis defined as the total costs required to test and treat one woman for syphilis were estimated. Results A total of 2214 women were tested in the study facilities. Cost per pregnant woman tested and cost per woman treated for syphilis were US$10.26 and US$607.99, respectively in the single RDT arm. For the dual RDTs, the cost per pregnant woman tested for HIV and syphilis and cost per woman treated for syphilis were US$15.89 and US$1859.26, respectively. Overall costs per woman tested for HIV and syphilis and cost per woman treated for syphilis were lower in Cali compared with Bogota across both intervention arms. Staff costs accounted for the largest proportion of costs while treatment costs comprised <1% of the preventive programme. Conclusions Findings show lower average costs for single RDTs compared with dual RDTs with costs sensitive to personnel costs and the scale of output at the health facilities. Trial registration number NCT02454816; results.
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Affiliation(s)
- Carol Dayo Obure
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Hernando Gaitan-Duarte
- Obstetrics and Gynecology Department, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Ricardo Losada Saenz
- Obstetrics and Gynecology Department, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Lina Gonzalez
- Obstetrics and Gynecology Department, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Edith Angel-Muller
- Obstetrics and Gynecology Department, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Maura Laverty
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Freddy Perez
- Communicable Diseases and Health Analysis Department, HIV, Hepatitis, Tuberculosis and Sexually Transmitted Infections Unit, Pan American Health Organization, Washington DC, USA
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Masha SC, Wahome E, Vaneechoutte M, Cools P, Crucitti T, Sanders EJ. High prevalence of curable sexually transmitted infections among pregnant women in a rural county hospital in Kilifi, Kenya. PLoS One 2017; 12:e0175166. [PMID: 28362869 PMCID: PMC5375155 DOI: 10.1371/journal.pone.0175166] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 03/21/2017] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Women attending antenatal care (ANC) in resource-limited countries are frequently screened for syphilis and HIV, but rarely for other sexually transmitted infections (STIs). We assessed the prevalence of curable STIs, defined as infection with either Chlamydia trachomatis or Neisseria gonorrhoeae or Trichomonas vaginalis, from July to September 2015. METHODS In a cross-sectional study, women attending ANC at the Kilifi County Hospital, Kenya, had a urine sample tested for C. trachomatis/N. gonorrhoeae by GeneXpert® and a vaginal swab for T. vaginalis by culture. Bacterial vaginosis (BV) was defined as a Nugent score of 7-10 of the Gram stain of a vaginal smear in combination with self-reported vaginal discharge. Genital ulcers were observed during collection of vaginal swabs. All women responded to questions on socio-demographics and sexual health and clinical symptoms of STIs. Predictors for curable STIs were assessed in multivariable logistic regression. RESULTS A total of 42/202 (20.8%, 95% confidence interval (CI):15.4-27.0) women had a curable STI. The prevalence was 14.9% for C. trachomatis (95% CI:10.2-20.5), 1.0% for N. gonorrhoeae (95% CI: 0.1-3.5), 7.4% for T. vaginalis (95% CI:4.2-12.0), 19.3% for BV (95% CI: 14.1-25.4) and 2.5% for genital ulcers (95% CI: 0.8-5.7). Predictors for infection with curable STIs included women with a genital ulcer (adjusted odds ratio (AOR) = 35.0, 95% CI: 2.7-461.6) compared to women without a genital ulcer, women who used water for cleaning after visiting the toilet compared to those who used toilet paper or other solid means (AOR = 4.1, 95% CI:1.5-11.3), women who reported having sexual debut ≤ 17 years compared to women having sexual debut ≥18 years (AOR = 2.7, 95% CI:1.1-6.6), and BV-positive women (AOR = 2.7, 95% CI:1.1-6.6) compared to BV-negative women. CONCLUSION One in five women attending ANC had a curable STI. These infections were associated with genital ulcers, hygiene practices, early sexual debut and bacterial vaginosis.
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Affiliation(s)
- Simon Chengo Masha
- Centre for Geographic Medicine Research–Coast, Kenya Medical Research Institute (KEMRI), Kilifi, Kenya
- Laboratory Bacteriology Research, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Pwani University, Faculty of Pure and Applied Sciences, Department of Biological Sciences, Kilifi, Kenya
| | - Elizabeth Wahome
- Centre for Geographic Medicine Research–Coast, Kenya Medical Research Institute (KEMRI), Kilifi, Kenya
| | - Mario Vaneechoutte
- Laboratory Bacteriology Research, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Piet Cools
- Laboratory Bacteriology Research, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Tania Crucitti
- HIV/STI Reference Laboratory, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Eduard J. Sanders
- Centre for Geographic Medicine Research–Coast, Kenya Medical Research Institute (KEMRI), Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Headington, United Kingdom
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Marks M, Mabey DC. The introduction of syphilis point of care tests in resource limited settings. Expert Rev Mol Diagn 2017; 17:321-325. [PMID: 28266230 DOI: 10.1080/14737159.2017.1303379] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Syphilis remains an important and preventable cause of stillbirth and neonatal mortality. About 1 million women with active syphilis become pregnant each year. Without treatment, 25% of them will deliver a stillborn baby and 33% a low birth weight baby with an increased chance of dying in the first month of life. Adverse pregnancy outcomes due to syphilis can be prevented by screening pregnant women, and treating those who test positive with a single dose of penicillin before 28 weeks' gestation. Areas covered: This manuscript covers the impact of syphilis on pregnancy outcome, the diagnosis of syphilis, with a special focus on point of care (POC) tests, and challenges to the introduction of POC tests, and their potential impact on the control and prevention of syphilis in resource limited settings. Expert commentary: POC tests for syphilis are available which meet the ASSURED criteria, and could make syphilis screening accessible to all women anywhere in the world who attend an antenatal clinic. High quality dual POC tests for HIV and syphilis could ensure that well-funded programmes for the prevention of mother to child transmission of HIV can contribute towards increased coverage of antenatal syphilis screening, and prevent more than 300,000 adverse pregnancy outcomes due to syphilis annually. Alongside investment to increase availability of syphilis POC tests, operational research is needed to understand how best to improve screening of pregnant women and to translate test availability into improved pregnancy outcomes.
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Affiliation(s)
- Michael Marks
- a London School of Hygiene & Tropical Medicine , Keppel Street, London , WC1E 7HT
| | - David Cw Mabey
- a London School of Hygiene & Tropical Medicine , Keppel Street, London , WC1E 7HT
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19
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Sakala J, Chizuni N, Nzala S. A study on usefulness of a set of known risk factors in predicting maternal syphilis infections in three districts of Western Province, Zambia. Pan Afr Med J 2016; 24:75. [PMID: 27703597 PMCID: PMC5031372 DOI: 10.11604/pamj.2016.24.75.8425] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 02/01/2016] [Indexed: 11/25/2022] Open
Abstract
Introduction Despite roll-out of cost-effective point-of-care tests, less than half antenatal attendees in rural western Zambia are screened for syphilis. This study formulated a clinical, risk-based assessment criteria and evaluated its usefulness as a non-biomedical alternative for identifying high-risk prenatal cases. Methods We conducted a cross-sectional survey of antenatal clinic attendees in Kaoma, Luampa and Nkeyema districts to collect data on exposure to nine pre-selected syphilis risk factors. These factors were classified into major and minor factors based on their observed pre-study association strengths to maternal syphilis. Clinical disease was defined as exposure to either two major factors, one major with two minor factors or three minor factors. Sensitivity, specificity and predictive values of the clinical protocol were then calculated in comparison to rapid plasmin reagin results. Results The observed syphilis prevalence was 9.3% (95% CI: 7.4 - 11.6%) and the overall sensitivity of the study criteria was 62.3% with positive predictive value of 72.9%. Sensitivities of individual case-defining categories were even lower; from 17.4% to 33.3%. Results confirmed that abortion history, still birth, multiple sexual partners, previous maternal syphilis infection, partner history of sexually transmitted infection and maternal co-morbid conditions of HIV and genital ulcer disease were significantly associated to maternal syphilis in study population as well. Conclusion The criteria was not as effective as biomedical tests in identifying maternal syphilis. However, it could be a useful adjunct/alternative in antenatal clinics when biomedical tests are either inadequate or unavailable.
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Affiliation(s)
- Jacob Sakala
- Department of Public Health, University of Zambia, School of Medicine, Lusaka, Zambia; Kaoma District Medical Office, Ministry of Health, Kaoma, Zambia
| | - Nellisiwe Chizuni
- Department of Public Health, University of Zambia, School of Medicine, Lusaka, Zambia
| | - Selestine Nzala
- Department of Public Health, University of Zambia, School of Medicine, Lusaka, Zambia
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20
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Marks M, Yin YP, Chen XS, Castro A, Causer L, Guy R, Wangnapi R, Mitjà O, Aziz A, Castro R, da Luz Martins Pereira F, Taleo F, Guinard J, Bélec L, Tun Y, Bottomley C, Ballard RC, Mabey DCW. Metaanalysis of the Performance of a Combined Treponemal and Nontreponemal Rapid Diagnostic Test for Syphilis and Yaws. Clin Infect Dis 2016; 63:627-633. [PMID: 27217216 PMCID: PMC4981758 DOI: 10.1093/cid/ciw348] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/14/2016] [Indexed: 02/01/2023] Open
Abstract
A combined treponemal and nontreponemal rapid diagnostic test was found to have good sensitivity and specificity for both syphilis and yaws. The performance of both the treponemal and nontreponemal test components was strongly associated with the rapid plasma reagin titer. Background. The human treponematoses are important causes of disease. Mother-to-child transmission of syphilis remains a major cause of stillbirth and neonatal death. There are also almost 100 000 cases of endemic treponemal disease reported annually, predominantly yaws. Rapid diagnostic tests (RDTs) would improve access to screening for these diseases. Most RDTs cannot distinguish current and previous infection. The Dual Path Platform (DPP) Syphilis Screen & Confirm test includes both a treponemal (T1) and nontreponemal (T2) component and may improve the accuracy of diagnosis. Methods. We conducted a metaanalysis of published and unpublished evaluations of the DPP-RDT for the diagnosis of syphilis and yaws. We calculated the sensitivity, specificity, and overall agreement of the test compared with reference laboratory tests. Results. Nine evaluations, including 7267 tests, were included. Sensitivity was higher in patients with higher titer rapid plasma reagin (≥1:16) for both the T1 (98.2% vs 90.1%, P < .0001) and the T2 component (98.2% vs 80.6%, P < .0001). Overall agreement between the DPP test and reference serology was 85.2% (84.4%–86.1%). Agreement was highest for high-titer active infection and lowest for past infection. Conclusions. The RDT has good sensitivity and specificity of the treponemal and nontreponemal components both in cases of suspected syphilis and yaws, although the sensitivity is decreased at lower antibody titers.
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Affiliation(s)
- Michael Marks
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine.,Hospital for Tropical Diseases, University College London Hospitals NHS Trust, United Kingdom
| | - Yue-Ping Yin
- National Center for STD Control, China Center for Disease Control and Prevention, Beijing.,Chinese Academy of Medical Sciences Institute of Dermatology and Hospital of Skin Diseases, Nanjing, China
| | - Xiang-Sheng Chen
- National Center for STD Control, China Center for Disease Control and Prevention, Beijing.,Chinese Academy of Medical Sciences Institute of Dermatology and Hospital of Skin Diseases, Nanjing, China
| | - Arnold Castro
- Laboratory Reference & Research Branch, Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Louise Causer
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Rebecca Guy
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Regina Wangnapi
- Papua New Guinea Institute of Medical Research, Goroka, Eastern Highland Province
| | - Oriol Mitjà
- Barcelona Institute for Global Health, Barcelona Centre for International Health Research, Hospital Clinic, University of Barcelona, Spain.,Lihir Medical Centre, International SOS, Newcrest Mining, Lihir Island, Papua New Guinea
| | | | - Rita Castro
- Unidade de Microbiologica Médica, Instituto de Higiene e Medicina Tropical, Lisbon, Portugal
| | | | | | - Jérôme Guinard
- Laboratoire de Microbiologie, Centre Hospitalier Régional d'Orléans
| | - Laurent Bélec
- Laboratoire de Microbiologie, hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris.,Faculté de Médecine Paris Descartes, Université Paris Descartes (Paris V), Sorbonne Paris Cité, France
| | - Ye Tun
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christian Bottomley
- Department of Infectious Diseases Epidemiology, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Ronald C Ballard
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David C W Mabey
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine.,Hospital for Tropical Diseases, University College London Hospitals NHS Trust, United Kingdom
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Kiarie J, Mishra CK, Temmerman M, Newman L. Accelerating the dual elimination of mother-to-child transmission of syphilis and HIV: Why now? Int J Gynaecol Obstet 2016; 130 Suppl 1:S1-3. [PMID: 26096725 DOI: 10.1016/j.ijgo.2015.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - Chandra K Mishra
- National Rural Health Mission, Ministry of Health and Family Welfare, Delhi, India
| | | | - Lori Newman
- Department of Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland.
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Rapid Syphilis Testing Is Cost-Effective Even in Low-Prevalence Settings: The CISNE-PERU Experience. PLoS One 2016; 11:e0149568. [PMID: 26949941 PMCID: PMC4780822 DOI: 10.1371/journal.pone.0149568] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 02/01/2016] [Indexed: 11/19/2022] Open
Abstract
Studies have addressed cost-effectiveness of syphilis testing of pregnant women in high-prevalence settings. This study compares costs of rapid syphilis testing (RST) with laboratory-based rapid plasma reagin (RPR) tests in low-prevalence settings in Peru. The RST was introduced in a tertiary-level maternity hospital and in the Ventanilla Network of primary health centers, where syphilis prevalence is approximately 1%. The costs per woman tested and treated with RST at the hospital were $2.70 and $369 respectively compared with $3.60 and $740 for RPR. For the Ventanilla Network the costs per woman tested and treated with RST were $3.19 and $295 respectively compared with $5.55 and $1454 for RPR. The cost per DALY averted using RST was $46 vs. $109 for RPR. RST showed lower costs compared to the WHO standard costs per DALY ($64). Findings suggest syphilis screening with RST is cost-effective in low-prevalence settings.
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