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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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Moseley P, Bamford A, Eisen S, Lyall H, Kingston M, Thorne C, Piñera C, Rabie H, Prendergast AJ, Kadambari S. Resurgence of congenital syphilis: new strategies against an old foe. THE LANCET. INFECTIOUS DISEASES 2024; 24:e24-e35. [PMID: 37604180 DOI: 10.1016/s1473-3099(23)00314-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 05/01/2023] [Accepted: 05/09/2023] [Indexed: 08/23/2023]
Abstract
Congenital syphilis is a major global cause of fetal loss, stillbirth, neonatal death, and congenital infection. In 2020, the global rate of congenital syphilis was 425 cases per 100 000 livebirths-substantially higher than WHO's elimination target of 50 cases per 100 000 livebirths. Case rates are rising in many high-income countries, but remain low compared with those in low-income and middle-income settings. This Review aims to summarise the current epidemiology and knowledge on transmission and treatment of syphilis in pregnancy, and proposes measures to reduce the rising incidence seen worldwide. We also describe emerging diagnostic and treatment tools to prevent vertical transmission and improve management of congenital syphilis. Finally, we outline a programme of public health priorities, which include research, clinical, and preventive strategies.
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Affiliation(s)
- Philip Moseley
- University of Queensland Frazer Institute, University of Queensland, Brisbane, QLD, Australia
| | - Alasdair Bamford
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; University College London Great Ormond Street Institute of Child Health, London, UK
| | - Sarah Eisen
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | - Claire Thorne
- University College London Great Ormond Street Institute of Child Health, London, UK
| | | | - Helena Rabie
- Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa; Tygerberg Academic Hospital, Cape Town, South Africa
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; Blizard Institute, Queen Mary University of London, London, UK
| | - Seilesh Kadambari
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; University College London Great Ormond Street Institute of Child Health, London, UK.
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3
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Peeling RW, Mabey D, Chen XS, Garcia PJ. Syphilis. Lancet 2023; 402:336-346. [PMID: 37481272 DOI: 10.1016/s0140-6736(22)02348-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 09/16/2022] [Accepted: 11/10/2022] [Indexed: 07/24/2023]
Abstract
Syphilis is a sexually and vertically transmitted bacterial infection caused by the bacterium Treponema pallidum. Its prevalence is high in low-income and middle-income countries, and its incidence has increased in high-income countries in the last few decades among men who have sex with men. Syphilis is a major cause of adverse pregnancy outcomes in low-income and middle-income countries. Clinical features include a primary chancre at the point of inoculation, followed weeks later by the rash of secondary syphilis, a latent period, and in some cases, involvement of the eyes, CNS, and cardiovascular systems. It is diagnosed serologically. A single intramuscular dose of long-acting benzathine penicillin is recommended for people who have had syphilis for less than 1 year and longer courses for people with late latent syphilis. Control strategies include screening and treatment of all pregnant women, and targeted interventions for groups at high risk. Vaccine development, research on antibiotic prophylaxis, and digital messaging as prevention strategies are ongoing.
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Affiliation(s)
- Rosanna W Peeling
- London School of Hygiene & Tropical Medicine, London, UK; University of Manitoba, Winnipeg, MB, Canada.
| | - David Mabey
- London School of Hygiene & Tropical Medicine, London, UK
| | - Xiang-Sheng Chen
- Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China; National Center for STD Control, Nanjing, China; Center for Global Health, Southern Medical University, Guangzhou, China
| | - Patricia J Garcia
- School of Public Health, Universidad Peruana Cayetano Heredia, Lima, Peru; University of Washington, Seattle, WA, USA
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4
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Koliou M, Chatzicharalampous E, Charalambous M, Aristeidou K. Congenital syphilis as the cause of multiple bone fractures in a young infant case report. BMC Pediatr 2022; 22:728. [PMID: 36539748 PMCID: PMC9768959 DOI: 10.1186/s12887-022-03789-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The differential diagnosis of multiple unexplained bone fractures in a young infant usually includes child abuse or bone disease such as osteogenesis imperfecta. Bone abnormalities can occur in 60-80% of cases with congenital syphilis and may be the sole manifestation. However, this frequent manifestation of this rare disease such as congenital syphilis is frequently disregarded. We describe a case of a young infant with multiple long bone fractures diagnosed with congenital syphilis. CASE PRESENTATION This 2-month-old male patient was referred to our hospital because of fractures of the ulna and distal radius bilaterally and noisy breathing with the suspicion of osteogenesis imperfecta. After thorough examination, the infant had anemia and a palpable spleen. We performed a screen for congenital infections among other investigations, which revealed positive non-treponemal and treponemal antibodies for syphilis. Hence the diagnosis for Congenital Syphilis was made. We performed a lumbar puncture (LP) which showed mild pleocytosis. The patient was treated with intravenous aqueous penicillin G 200 000 UI/KG per day for 10 days. In addition, a single dose of intramuscular penicillin G benzathine 50 000 UI/KG was given due to the abnormal result of CSF. On follow up admission 6 months later, the new syphilis serology had much improved and the new LP revealed no abnormal findings. CONCLUSIONS We present this case report in order to remind of a common manifestation of congenital syphilis, a rare disease which needs to be included in the differential diagnosis of multiple unexplained fractures in early infancy. In our case the fractures were symmetric and bilateral and they were accompanied by anemia and mild hepatosplenomegaly which led to the investigation of congenital syphilis as a possible cause. However, two thirds of infants with congenital syphilis are asymptomatic at birth. All women should have a proper syphilis screening during pregnancy.
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Affiliation(s)
- Maria Koliou
- grid.6603.30000000121167908Medical School, University of Cyprus, Palaios Dromos Lefkosias- Lemesou, 5 Agiou Symeon Street, Strovolos, Nicosia, 2037 Cyprus ,grid.416318.90000 0004 4684 9173Department of Paediatrics, Archbishop Makarios III Hospital, 6 Korytsas Str, 2012 Nicosia, Cyprus
| | - Elpida Chatzicharalampous
- grid.416318.90000 0004 4684 9173Department of Paediatrics, Archbishop Makarios III Hospital, 6 Korytsas Str, 2012 Nicosia, Cyprus
| | - Myria Charalambous
- grid.416318.90000 0004 4684 9173Department of Paediatrics, Archbishop Makarios III Hospital, 6 Korytsas Str, 2012 Nicosia, Cyprus
| | - Kyriakos Aristeidou
- grid.416318.90000 0004 4684 9173Department of Radiology, Archbishop Makarios III Hospital, 6 Korytsas Str, 2012 Nicosia, Cyprus
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5
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Verbeke E, Luyten J. Future Offspring Costs in Economic Evaluation. PHARMACOECONOMICS 2022; 40:141-147. [PMID: 34713421 DOI: 10.1007/s40273-021-01102-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 06/13/2023]
Abstract
Economic evaluation guidelines increasingly prescribe inclusion of all future costs. We point at an important dimension of future costs that is systematically neglected. Healthcare can affect future offspring, either through affecting the patient's fertility or through determining future offspring's health. As we show, the future costs associated with these changes can be substantial and will vary across interventions and demographic groups. However, systematic inclusion of these future offspring costs would raise many problems on its own. Based on the population ethics concept of necessitarianism, we suggest that only those future costs that spring from 'necessary' future lives should be included in future cost calculations, while all costs associated with 'potential' future lives can be ignored. This approach allows excluding most future offspring costs and avoids skewed cost-effectiveness outcomes of interventions with fertility effects, while taking into account the economic implications of preventing disease in future generations that will exist by necessity. Overall, future generations expose a substantial gap in today's Health Technology Assessment (HTA) methodology and further discussion of the issues they raise is needed.
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Affiliation(s)
- Evelyn Verbeke
- Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium.
| | - Jeroen Luyten
- Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium
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6
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Karamagi HC, Berhane A, Ngusbrhan Kidane S, Nyawira L, Ani-Amponsah M, Nyanjau L, Maoulana K, Seydi ABW, Nzinga J, Dangou JM, Nkurunziza T, K Bisoborwa G, Sillah JS, W Muriithi A, Nirina Razakasoa H, Bigirimana F. High impact health service interventions for attainment of UHC in Africa: A systematic review. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000945. [PMID: 36962639 PMCID: PMC10021619 DOI: 10.1371/journal.pgph.0000945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 08/23/2022] [Indexed: 11/19/2022]
Abstract
African countries have prioritized the attainment of targets relating to Universal Health Coverage (UHC), Health Security (HSE) and Coverage of Health Determinants (CHD)to attain their health goals. Given resource constraints, it is important to prioritize implementation of health service interventions with the highest impact. This is important to be identified across age cohorts and public health functions of health promotion, disease prevention, diagnostics, curative, rehabilitative and palliative interventions. We therefore explored the published evidence on the effectiveness of existing health service interventions addressing the diseases and conditions of concern in the Africa Region, for each age cohort and the public health functions. Six public health and economic evaluation databases, reports and grey literature were searched. A total of 151 studies and 357 interventions were identified across different health program areas, public health functions and age cohorts. Of the studies, most were carried out in the African region (43.5%), on communicable diseases (50.6%), and non-communicable diseases (36.4%). Majority of interventions are domiciled in the health promotion, disease prevention and curative functions, covering all age cohorts though the elderly cohort was least represented. Neonatal and communicable conditions dominated disease burden in the early years of life and non-communicable conditions in the later years. A menu of health interventions that are most effective at averting disease and conditions of concern across life course in the African region is therefore consolidated. These represent a comprehensive evidence-based set of interventions for prioritization by decision makers to attain desired health goals. At a country level, we also identify principles for identifying priority interventions, being the targeting of higher implementation coverage of existing interventions, combining interventions across all the public health functions-not focusing on a few functions, provision of subsidies or free interventions and prioritizing early identification of high-risk populations and communities represent these principles.
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Affiliation(s)
- Humphrey Cyprian Karamagi
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Araia Berhane
- Conmmunicable Diseases Control Division, Ministry of Health, Asmara, Eritrea
| | - Solyana Ngusbrhan Kidane
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Lizah Nyawira
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | | | | | - Koulthoume Maoulana
- Ministry of Health, Solidarity, Social Protection and Gender Promotion, Moroni, Comoros
| | - Aminata Binetou Wahebine Seydi
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Jacinta Nzinga
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
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7
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Lingani M, Zango SH, Valéa I, Bonko MDA, Samadoulougou SO, Rouamba T, Tahita MC, Sanou M, Robert A, Tinto H, Donnen P, Dramaix M. Malaria and curable sexually transmitted and reproductive tract coinfection among pregnant women in rural Burkina Faso. Trop Med Health 2021; 49:90. [PMID: 34736524 PMCID: PMC8567650 DOI: 10.1186/s41182-021-00381-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 10/27/2021] [Indexed: 11/11/2022] Open
Abstract
Background Malaria and sexually transmitted/reproductive tract infections (STI/RTI) are leading and preventable causes of low birthweight in sub-Saharan Africa. Reducing their impact on pregnancy outcomes requires efficient interventions that can be easily integrated into the antenatal care package. The paucity of data on malaria and STI/RTI coinfection, however, limits efforts to control these infections. This study aimed to determine the prevalence and associated factors of malaria and STI/RTI coinfection among pregnant women in rural Burkina Faso.
Methods A cross-sectional survey was conducted among 402 pregnant women attending antenatal clinics at the Yako health district. Sociodemographic and behavioral data were collected, and pregnant women were tested for peripheral malaria by microscopy. Hemoglobin levels were also measured by spectrophotometry and curable bacterial STI/RTI were tested on cervico-vaginal swabs using rapid diagnostic test for chlamydia and syphilis, and Gram staining for bacterial vaginosis. A multivariate logistic regression model was used to assess the association of malaria and STI/RTI coinfection with the characteristics of included pregnant women.
Results The prevalence of malaria and at least one STI/RTI coinfection was 12.9% (95% confidence interval, CI: [9.8–16.7]), malaria and bacterial vaginosis coinfection was 12.2% (95% CI: [9.3–15.9]), malaria and chlamydial coinfection was 1.6% (95% CI: [0.6–3.8]). No coinfection was reported for malaria and syphilis. The individual prevalence was 17.2%, 7.2%, 0.6%, 67.7% and 73.3%, respectively, for malaria infection, chlamydia, syphilis, bacterial vaginosis and STI/RTI combination. Only 10% of coinfections were symptomatic, and thus, 90% of women with coinfection would have been missed by the symptoms-based diagnostic approach. In the multivariate analysis, the first pregnancy (aOR = 2.4 [95% CI: 1.2–4.7]) was the only factor significantly associated with malaria and STI/RTI coinfection. Clinical symptoms were not associated with malaria and STI/RTI coinfection. Conclusion The prevalence of malaria and curable STI/RTI coinfection was high among pregnant women. The poor performance of the clinical symptoms to predict coinfection suggests that alternative interventions are needed.
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Affiliation(s)
- Moussa Lingani
- École de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique. .,Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso.
| | - Serge H Zango
- Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso.,Epidemiology and Biostatistics Research Division, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Bruxelles, Belgique
| | - Innocent Valéa
- Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
| | - Massa Dit A Bonko
- Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
| | - Sékou O Samadoulougou
- Evaluation Platform On Obesity Prevention, Quebec Heart and Lung Institute Research Center, Quebec, Canada
| | - Toussaint Rouamba
- Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
| | - Marc C Tahita
- Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
| | - Maïmouna Sanou
- Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
| | - Annie Robert
- Epidemiology and Biostatistics Research Division, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Bruxelles, Belgique
| | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé/Direction Régionale du Centre Ouest (IRSS/DRCO), Nanoro, Burkina Faso
| | - Philippe Donnen
- École de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
| | - Michèle Dramaix
- École de Santé Publique, Université Libre de Bruxelles, Bruxelles, Belgique
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8
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Zhou Q, Yang Y, Wang L, Chen X, Xu Q, Wang Q, Shen H, Xu Z, Zhang Y, Yan D, Peng Z, He Y, Wang Y, Li X, Ma X. Intra-couple discordance in preconception syphilis screening for both spouses: a national and population-based survey in China, 2013-2018. BJOG 2021; 129:313-321. [PMID: 34532971 DOI: 10.1111/1471-0528.16923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The antenatal screening strategy remains inadequate for eliminating congenital syphilis. To further eliminate maternal fetal transmission, preconception syphilis screening is considered an option. In this study, we investigated syphilis seropositivity and intra-couple discordance among married couples planning a pregnancy in China to provide essential baseline evidence for preconception syphilis screening. DESIGN Population-based survey. SETTING National preconception registered data. POPULATION Married Chinese couples planning conception within 6 months between 2013 and 2018. METHODS Syphilis was screened using rapid plasma reagin (RPR); infection self-reporting and sociodemographic characteristics were collected through questionnaires and medical records, respectively. r 3.2.2 and arcgis 10.2 were used for statistical analyses and geographic mapping. MAIN OUTCOME MEASURES RPR seropositivity. RESULTS Among 31 955 041 couples, 29 737 172 (93.06%) had complete RPR results for both spouses; of those, 0.62% (186 100) were seropositive, with dramatic intra-couple discordance, with 0.33% positivity in wives, 0.24% positivity in husbands and 0.05% positivity in both spouses. Across time, both seropositivity and intra-couple discordance remained stable. Seropositivity in different regions varied significantly, with provincial rates ranging geographically from Tibet (0.8%) to Hebei (0.2%) (P < 0.05). Economic level was an independent factor for this regional variation, with seropositivity increasing as gross domestic product income decreased (P < 0.05). CONCLUSIONS Intra-couple discordance in seropositivity for syphilis is notable among couples, with a considerable rate of pre-existing syphilis before pregnancy. Thus, screening both spouses during integrated preconception health care is recommended for further eliminating maternal-fetal transmission. TWEETABLE ABSTRACT Intra-couple discordance in seropositivity for syphilis is notable among couples, with a considerable rate of pre-existing syphilis before pregnancy. Screening both spouses during integrated preconception health care is recommended to further eliminate maternal-fetal transmission.
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Affiliation(s)
- Q Zhou
- Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China.,Women's Health and Perinatology Research Group, Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Y Yang
- National Research Institute for Family Planning, Beijing, China.,National Human Genetic Resources Center, Beijing, China
| | - L Wang
- National Research Institute for Family Planning, Beijing, China.,Graduate School of Peking Union Medical College, Beijing, China.,School of Public Health, Institute for Epidemiology and Statistics, Lanzhou University, Lanzhou, China
| | - X Chen
- Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China
| | - Q Xu
- National Research Institute for Family Planning, Beijing, China.,Graduate School of Peking Union Medical College, Beijing, China
| | - Q Wang
- Department of Maternal and Child Health, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - H Shen
- Department of Maternal and Child Health, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Z Xu
- Department of Maternal and Child Health, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Y Zhang
- Department of Maternal and Child Health, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - D Yan
- Department of Maternal and Child Health, National Health and Family Planning Commission of the People's Republic of China, Beijing, China
| | - Z Peng
- National Research Institute for Family Planning, Beijing, China.,National Human Genetic Resources Center, Beijing, China
| | - Y He
- National Research Institute for Family Planning, Beijing, China.,National Human Genetic Resources Center, Beijing, China
| | - Y Wang
- National Research Institute for Family Planning, Beijing, China.,National Human Genetic Resources Center, Beijing, China
| | - X Li
- Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China.,Institute of Biomedical Sciences, Fudan University, Shanghai, China
| | - X Ma
- National Research Institute for Family Planning, Beijing, China.,National Human Genetic Resources Center, Beijing, China.,Graduate School of Peking Union Medical College, Beijing, China
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9
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Mabey D, Okomo U, Greenwood B. Priorities in reducing child mortality: Azithromycin and other interventions. PLoS Med 2020; 17:e1003364. [PMID: 32931499 PMCID: PMC7491718 DOI: 10.1371/journal.pmed.1003364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In this Perspective, David Mabey and colleagues discuss a recent PLOS Medicine article on azithromycin as an intervention for reducing child mortality.
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Affiliation(s)
- David Mabey
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Uduak Okomo
- MRC Unit The Gambia at London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Brian Greenwood
- Disease Control Department, London School of Hygiene & Tropical Medicine, London, United Kingdom
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10
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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: 2] [Impact Index Per Article: 0.5] [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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11
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Zhang L, Tao Y, Woodring J, Rattana K, Sovannarith S, Rathavy T, Cheang K, Hossain S, Ferradini L, Deng S, Sokun C, Samnang C, Nagai M, Lo YR, Ishikawa N. Integrated approach for triple elimination of mother-to-child transmission of HIV, hepatitis B and syphilis is highly effective and cost-effective: an economic evaluation. Int J Epidemiol 2020; 48:1327-1339. [PMID: 30879066 DOI: 10.1093/ije/dyz037] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Regional Framework for Triple Elimination of Mother-to-Child Transmission (EMTCT) of HIV, Hepatitis B (HBV) and Syphilis in Asia and the Pacific 2018-30 was endorsed by the Regional Committee of WHO Western Pacific in October 2017, proposing an integrated and coordinated approach to achieve elimination in an efficient, coordinated and sustainable manner. This study aims to assess the population impacts and cost-effectiveness of this integrated approach in the Cambodian context. METHODS Based on existing frameworks for the EMTCT for each individual infection, an integrated framework that combines infection prevention procedures with routine antenatal care was constructed. Using decision tree analyses, population impacts, cost-effectiveness and the potential reduction in required resources of the integrated approach as a result of resource pooling and improvements in service coverage and coordination, were evaluated. The tool was assessed using simulated epidemiological data from Cambodia. RESULTS The current prevention programme for 370,000 Cambodian pregnant women was estimated at USD$2.3 ($2.0-$2.5) million per year, including the duration of pregnancy and up to 18 months after delivery. A model estimate of current MTCT rates in Cambodia was 6.6% (6.2-7.1%) for HIV, 14.1% (13.1-15.2%) for HBV and 9.4% (9.0-9.8%) for syphilis. Integrating HIV and syphilis prevention into the existing antenatal care framework will reduce the total time required to provide this integrated care by 19% for health care workers and by 32% for pregnant women, resulting in a net saving of $380,000 per year for the EMTCT programme. This integrated approach reduces HIV and HBV MTCT to 6.1% (5.7-6.5%) and 13.0% (12.1-14.0%), respectively, and substantially reduces syphilis MCTC to 4.6% (4.3-5.0%). Further introduction of either antiviral treatment for pregnant women with high viral load of HBV, or hepatitis B immunoglobulin (HBIG) to exposed newborns, will increase the total cost of EMTCT to $4.4 ($3.6-$5.2) million and $3.3 ($2.7-$4.0) million per year, respectively, but substantially reduce HBV MTCT to 3.5% (3.2-3.8%) and 5.0% (4.6-5.5%), respectively. Combining both antiviral and HBIG treatments will further reduce HBV MTCT to 3.4% (3.1-3.7%) at an increased total cost of EMTCT of $4.5 ($3.7-$5.4) million per year. All these HBV intervention scenarios are highly cost-effective ($64-$114 per disability-adjusted life years averted) when the life benefits of these prevention measures are considered. CONCLUSIONS The integrated approach, using antenatal, perinatal and postnatal care as a platform in Cambodia for triple EMTCT of HIV, HBV and syphilis, is highly cost-effective and efficient.
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Affiliation(s)
- Lei Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, PR China.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia.,Central Clinical School.,School of Public Health and Preventive Medicine, Faculty of Medicine, Monash University, Melbourne, VIC, Australia
| | - Yusha Tao
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, PR China
| | - Joseph Woodring
- World Health Organization, Regional Office of the Western Pacific, Division of Communicable Diseases, Expanded Programme for Immunization, Manila, Philippines
| | - Kim Rattana
- National Program on Prevention of Mother to Child Transmission, Cambodia
| | | | - Tung Rathavy
- World Health Organization, Country Office of Cambodia
| | | | - Shafiqul Hossain
- National Professional Officer, Expanded Programme on Immunization, Cambodia
| | - Laurent Ferradini
- National Professional Officer, Expanded Programme on Immunization, Cambodia
| | - Serongkea Deng
- National Professional Officer, Expanded Programme on Immunization, Cambodia
| | - Chay Sokun
- National Professional Officer, Expanded Programme on Immunization, Cambodia
| | - Chham Samnang
- National Professional Officer, Expanded Programme on Immunization, Cambodia
| | - Mari Nagai
- World Health Organization Regional Office of the Western Pacific, Division of Non-Communicable Diseases and Health through Life-Course, Reproductive, Maternal, Newborn, Child and Adolescent Health
| | - Ying-Ru Lo
- WHO Country Office for Malaysia, Brunei Darussalam and Singapore
| | - Naoko Ishikawa
- World Health Organization, Regional Office of the Western Pacific, Division of Communicable Diseases, HIV, Hepatitis and STI Unit
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12
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Treatment evaluation to improve preventing mother to child transmission among women with syphilis. Sci Rep 2019; 9:19547. [PMID: 31862938 PMCID: PMC6925227 DOI: 10.1038/s41598-019-56095-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 12/06/2019] [Indexed: 11/17/2022] Open
Abstract
The aim of this study was to evaluate the effectiveness of preventing mother to child syphilis transmission to improve pregnancy outcomes. We performed a retrospective analysis of municipal databases of mother-to-child syphilis transmission. Pregnant women with syphilis were included. Group specific pregnancy outcomes were analyzed according to treatment. A total of 28 pregnant women were diagnosed with syphilis in 2012; 321 were diagnosed with syphilis in 2018. A prevalence of 0.14% was observed amongst pregnant women in Suzhou city from 2012–2018. Primary treatments included benzathine penicillin, ceftriaxone sodium or erythromycin when patients were allergic to Benzathine penicillin. The treatment coverage was 81.57%, and only 52.86% of pregnant women were adequately treated. Adverse pregnant outcomes were higher amongst untreated women. Expanding early screening coverage and promoting treatment were key to improving pregnancy outcomes amongst women with syphilis.
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13
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Tran BX, Nguyen LH, Turner HC, Nghiem S, Vu GT, Nguyen CT, Latkin CA, Ho CSH, Ho RCM. Economic evaluation studies in the field of HIV/AIDS: bibliometric analysis on research development and scopes (GAP RESEARCH). BMC Health Serv Res 2019; 19:834. [PMID: 31727059 PMCID: PMC6854742 DOI: 10.1186/s12913-019-4613-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 10/07/2019] [Indexed: 12/31/2022] Open
Abstract
Background The rapid decrease in international funding for HIV/AIDS has been challenging for many nations to effectively mobilize and allocate their limited resources for HIV/AIDS programs. Economic evaluations can help inform decisions and strategic planning. This study aims to examine the trends and patterns in economic evaluation studies in the field of HIV/AIDS and determine their research landscapes. Methods Using the Web of Science databases, we synthesized the number of papers and citations on HIV/AIDS and economic evaluation from 1990 to 2017. Collaborations between authors and countries, networks of keywords and research topics were visualized using frequency of co-occurrence and Jaccards’ similarity index. A Latent Dirichlet Allocation (LDA) analysis to categorize papers into different topics/themes. Results A total of 372 economic evaluation papers were selected, including 351 cost-effectiveness analyses (CEA), 11 cost-utility analyses (CUA), 12 cost-benefit analyses (CBA). The growth of publications, their citations and usages have increased remarkably over the years. Major research topics in economic evaluation studies consisted of antiretroviral therapy (ART) initiation and treatment; drug use prevention interventions and prevention of mother-to-child transmission interventions. Moreover, lack of contextualized evidence was found in specific settings with high burden HIV epidemics, as well as emerging most-at-risk populations such as trans-genders or migrants. Conclusion This study highlights the knowledge and geographical discrepancies in HIV/AIDS economic evaluation literature. Future research directions are also informed for advancing economic evaluation in HIV/AIDS research.
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Affiliation(s)
- Bach Xuan Tran
- Department of Health Economics, Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam. .,Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Long Hoang Nguyen
- Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, 70000, Vietnam
| | - Hugo C Turner
- Oxford University Clinical Research Unit, Ho Chi Minh City, 70000, Vietnam
| | - Son Nghiem
- Centre for Applied Health Economics, Griffith University, Brisbane, Australia
| | - Giang Thu Vu
- Center of Excellence in Evidence-based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, 70000, Vietnam
| | - Cuong Tat Nguyen
- Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam
| | - Carl A Latkin
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Cyrus S H Ho
- Department of Psychological Medicine, National University Hospital, Singapore, Singapore
| | - Roger C M Ho
- Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, 70000, Vietnam.,Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Singapore.,Biomedical Global Institute of Healthcare Research & Technology (BIGHEART), National University of Singapore, Singapore, 117599, Singapore
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14
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Congenital Syphilis Prevention: Strategies, Evidence, and Future Directions. Sex Transm Dis 2019; 45:S29-S37. [PMID: 29624562 DOI: 10.1097/olq.0000000000000846] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Congenital syphilis (CS)-the preventable transmission of Treponema pallidum from infected mother to fetus-remains a significant problem worldwide. METHODS From July through November 2017, 239 articles relevant to CS prevention were identified via keyword searches in PubMed and Google Scholar, ancestry searches, and expert recommendation. Articles were then assessed for (1) measurement of a specified CS or adverse pregnancy outcomes (APOs) and (2) geographic setting in high/upper middle income countries according to United Nations criteria. In total, 119 articles met inclusion criteria. These were then vetted for 1 of 3 arms of CS prevention, after which additional ancestral searches were conducted within each arm to arrive at the final collection of articles per CS prevention strategy-maternal prenatal treatment (n = 33), prenatal screening (n = 24), and public health interventions that support screening and treatment (n = 15). RESULTS Of the 7 studies that evaluated treatment with benzathine penicillin G (BPG) use within the context of a modern health care system, all showed BPG to be highly effective in CS prevention; 3 additional studies demonstrated BPG effectiveness in preventing APOs. Ten studies revealed early disease detection through prenatal screening significantly reduces CS and APOs when paired with BPG. There was limited literature evaluating public health interventions, such as partner notification, surveillance, and prenatal screening laws. CONCLUSIONS Congenital syphilis is a preventable disease, effectively avoided with appropriate prenatal screening and BPG therapy. Increasing syphilis rates among all adults, accompanied by gaps in the provision of prenatal care to women at high risk of infection, are major contributors to CS persistence.
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15
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Ogundipe OF, Van den Bergh R, Thierry B, Takarinda KC, Muller CP, Timire C, Caluwaerts S, Chaillet P, Zuniga I. Better care for babies: the added value of a modified reverse syphilis testing algorithm for the treatment of congenital syphilis in a maternity Hospital in Central African Republic. BMC Pediatr 2019; 19:284. [PMID: 31416437 PMCID: PMC6694671 DOI: 10.1186/s12887-019-1622-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 07/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In high syphilis prevalence settings, the syphilis testing and treatment strategy for mothers and newborns must be tailored to balance the risk of over treatment against the risk of missing infants at high-risk for congenital syphilis. Adding a non-treponemal test (Rapid Plasma Reagin - RPR) to a routine rapid treponemal test (SD Bioline Syphilis 3.0) for women giving birth can help distinguish between neonates at high and low-risk for congenital syphilis to tailor their treatment. Treatment for neonates born to RPR-reactive mothers (high-risk) is 10 days of intravenous penicillin, while one dose of intramuscular penicillin is sufficient for those born to RPR non-reactive mothers (low-risk). This strategy was adopted in March 2017 in a Médecins Sans Frontières supported hospital in Bangui, Central African Republic. This study examined the operational consequences of this algorithm on the treatment of newborns. METHODS The study was a retrospective cohort study. Routine programmatic data were analysed. Descriptive statistical analysis was done. Total antibiotic days, hospitalization days and estimated costs were compared to scenarios without RPR testing and another where syphilis treatment was the sole reason for hospitalization. RESULTS Of 202 babies born to SD Bioline positive mothers 89 (44%) and 111(55%) were RPR-reactive and non-reactive respectively (2 were unrecorded) of whom 80% and 88% of the neonates received appropriate antibiotic treatment respectively. Neonates born to RPR non-reactive mothers were 80% less likely to have sepsis [Relative risk (RR) = 0.20; 95% Confidence interval (CI) = 0.04-0.92] and 9% more likely to be discharged [RR = 1.09; 95% CI = 1.00-1.18] compared to those of RPR-reactive mothers. There was a 52%, and 49% reduction in antibiotic and hospitalization days respectively compared to a scenario with SD-Bioline testing only. Total hospitalization costs were also 52% lower compared to a scenario without RPR testing. CONCLUSIONS This testing strategy can help identify infants at high and low risk for congenital syphilis and treat them accordingly at substantial cost savings. It is especially appropriate for settings with high syphilis endemicity, limited resources and overcrowded maternities. The babies additionally benefit from lower risks of exposure to unnecessary antibiotics and nosocomial infections.
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Affiliation(s)
| | | | | | - Kudakwashe C Takarinda
- International Union Against Tuberculosis and Lung Disease, Paris, France.,Ministry of Health and Child Care, AIDS and TB Department, Harare, Zimbabwe.,International Union Against Tuberculosis and Lung Disease, Harare, Zimbabwe
| | - Claude P Muller
- Luxembourg Institute of Health, Esch-Alzette, and Laboratoire National de Santé, Dudelange, Grand Duchy of Luxembourg
| | - Collins Timire
- International Union Against Tuberculosis and Lung Disease, Paris, France.,Ministry of Health and Child Care, AIDS and TB Department, Harare, Zimbabwe.,International Union Against Tuberculosis and Lung Disease, Harare, Zimbabwe
| | | | - Pascale Chaillet
- Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
| | - Isabel Zuniga
- Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
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16
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Johns B, Hangoma P, Atuyambe L, Faye S, Tumwine M, Zulu C, Levitt M, Tembo T, Healey J, Li R, Mugasha C, Serbanescu F, Conlon CM. The Costs and Cost-Effectiveness of a District-Strengthening Strategy to Mitigate the 3 Delays to Quality Maternal Health Care: Results From Uganda and Zambia. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:S104-S122. [PMID: 30867212 PMCID: PMC6519668 DOI: 10.9745/ghsp-d-18-00429] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 01/27/2019] [Indexed: 11/15/2022]
Abstract
A comprehensive district-strengthening approach to address maternal and newborn health was estimated to cost US$177 per life-year gained in Uganda and $206 per life-year gained in Zambia. The approach represents a very cost-effective health investment compared to GDP per capita. The primary objective of this study was to estimate the costs and the incremental cost-effectiveness of maternal and newborn care associated with the Saving Mothers, Giving Life (SMGL) initiative—a comprehensive district-strengthening approach addressing the 3 delays associated with maternal mortality—in Uganda and Zambia. To assess effectiveness, we used a before-after design comparing facility outcome data from 2012 (before) and 2016 (after). To estimate costs, we used unit costs collected from comparison districts in 2016 coupled with data on health services utilization from 2012 in SMGL-supported districts to estimate the costs before the start of SMGL. We collected data from health facilities, ministerial health offices, and implementing partners for the year 2016 in 2 SMGL-supported districts in each country and in 3 comparison non-SMGL districts (2 in Zambia, 1 in Uganda). Incremental costs for maternal and newborn health care per SMGL-supported district in 2016 was estimated to be US$845,000 in Uganda and $760,000 in Zambia. The incremental cost per delivery was estimated to be $38 in Uganda and $95 in Zambia. For the districts included in this study, SMGL maternal and newborn health activities were associated with approximately 164 deaths averted in Uganda and 121 deaths averted in Zambia in 2016 compared to 2012. In Uganda, the cost per death averted was $10,311, or $177 per life-year gained. In Zambia, the cost per death averted was $12,514, or $206 per life-year gained. The SMGL approach can be very cost-effective, with the cost per life-year gained as a percentage of the gross domestic product (GDP) being 25.6% and 16.4% in Uganda and Zambia, respectively. In terms of affordability, the SMGL approach could be paid for by increasing health spending from 7.3% to 7.5% of GDP in Uganda and from 5.4% to 5.8% in Zambia.
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Affiliation(s)
- Benjamin Johns
- International Development Division, Abt Associates Inc., Bethesda, MD, USA.
| | - Peter Hangoma
- Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Lynn Atuyambe
- Department of Community Health and Behavioral Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sophie Faye
- International Development Division, Abt Associates Inc., Bethesda, MD, USA
| | - Mark Tumwine
- Uganda Country Office, U.S. Centers for Disease Control and Prevention, Entebbe, Uganda
| | - Collen Zulu
- U.S. Agency for International Development, Lusaka, Zambia
| | - Marta Levitt
- Bureau for Global Health, U.S. Agency for International Development, Washington, DC, USA, and RTI, Washington, DC, USA. Now with Palladium, Abuja, Nigeria
| | - Tannia Tembo
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Jessica Healey
- U.S. Agency for International Development, Lusaka, Zambia. Now based in Monrovia, Liberia
| | - Rui Li
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Florina Serbanescu
- Division of Reproductive Health, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
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17
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Walker GJA, Walker D, Molano Franco D, Grillo‐Ardila CF. Antibiotic treatment for newborns with congenital syphilis. Cochrane Database Syst Rev 2019; 2:CD012071. [PMID: 30776081 PMCID: PMC6378924 DOI: 10.1002/14651858.cd012071.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Congenital syphilis continues to be a substantial public health problem in many parts of the world. Since the first use of penicillin for the treatment of syphilis in 1943, which was a notable early success, it has remained the preferred and standard treatment including for congenital syphilis. However, the treatment of congenital syphilis is largely based on clinical experience and there is extremely limited evidence on the optimal dose or duration of administration of penicillin or the use of other antibiotics. OBJECTIVES To assess the effectiveness and safety of antibiotic treatment for newborns with confirmed, highly probable and possible congenital syphilis. SEARCH METHODS We searched the Cochrane STI Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, WHO ICTRP, ClinicalTrials.gov and Web of Science to 23 May 2018. We also handsearched conference proceedings, contacted trial authors and reviewed the reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing antibiotic treatment (any concentration, frequency, duration and route) with no intervention or any other antibiotic treatment for neonates with confirmed, highly probable or possible congenital syphilis. DATA COLLECTION AND ANALYSIS All review authors independently assessed trials for inclusion, extracted data and assessed the risk of bias in the included studies. We resolved any disagreements through consensus. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Two RCTs (191 participants) met our inclusion criteria and none of these trials was funded by the industry. One trial (22 participants) compared benzathine penicillin with no intervention for infants with possible congenital syphilis. Low-quality evidence suggested that benzathine penicillin administration may not have decreased the rate of neonatal death due to any cause (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.06 to 11.70), and showed a possible reduction into the proportion of neonates with clinical manifestations of congenital syphilis (RR 0.12, 95% CI 0.01 to 2.09). Penicillin administration increased the serological cure at the third month (RR 2.13, 95% CI 1.06 to 4.27). These results should be taken with caution, because the trial was stopped early because there were four cases with clinical congenital syphilis in the no treatment group and none in the treatment group. Interim analysis suggested this difference was significant. This study did not report neonatal death due to congenital syphilis or the frequency of serious or minor adverse events after therapy. We downgraded the quality of evidence because of imprecision and risk of bias.One trial (169 participants) compared benzathine penicillin versus procaine benzylpenicillin. High- and moderate-quality evidence suggested that there were probably no differences between benzathine penicillin and procaine benzylpenicillin for the outcomes: absence of clinical manifestations of congenital syphilis (RR 1.00, 95% CI 0.97 to 1.03) and serological cure (RR 1.00, 95% CI 0.97 to 1.03). There were no cases of neonatal death due congenital syphilis; all 152 babies who followed up survived. This study did not report on the frequency of serious or minor adverse events after therapy. We downgraded the quality of evidence because of serious risk of bias. AUTHORS' CONCLUSIONS At present, the evidence on the effectiveness and safety of antibiotic treatment for newborns with confirmed, highly probable or possible congenital syphilis is sparse, implying that we are uncertain about the estimated effect. One trial compared benzathine penicillin with no intervention for infants with possible congenital syphilis. Low-quality evidence suggested penicillin administration possibly reduce the proportion of neonates with clinical manifestations of congenital syphilis, penicillin administration increased the serological cure at the third month. These findings support the clinical use of penicillin in neonates with confirmed, highly probable or possible congenital syphilis. High- and moderate-quality evidence suggests that there are probably no differences between benzathine penicillin and procaine benzylpenicillin administration for the outcomes of absence of clinical manifestations of syphilis or serological cure.
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Affiliation(s)
- Godfrey JA Walker
- The University of LiverpoolC/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Damian Walker
- Bill & Melinda Gates FoundationCost‐Effectiveness, Integrated Delivery, Global DevelopmentSeattleUSAWA 98102
| | - Daniel Molano Franco
- Fundacion Universitaria de Ciencias de la Salud, Hospital de San JoséDepartment of Critical CareCarrera 19 # 8‐32BogotaBogotaColombia11001
| | - Carlos F Grillo‐Ardila
- Faculty of Medicine, Universidad Nacional de ColombiaDepartment of Obstetrics and GynecologyCarrera 30 No 45‐03BogotaColombia
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18
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Young N, Achieng F, Desai M, Phillips-Howard P, Hill J, Aol G, Bigogo G, Laserson K, Ter Kuile F, Taegtmeyer M. Integrated point-of-care testing (POCT) for HIV, syphilis, malaria and anaemia at antenatal facilities in western Kenya: a qualitative study exploring end-users' perspectives of appropriateness, acceptability and feasibility. BMC Health Serv Res 2019; 19:74. [PMID: 30691447 PMCID: PMC6348645 DOI: 10.1186/s12913-018-3844-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 12/19/2018] [Indexed: 11/17/2022] Open
Abstract
Background HIV, syphilis, malaria and anaemia are leading preventable causes of adverse pregnancy outcomes in sub-Saharan Africa yet testing coverage for conditions other than HIV is low. Availing point-of-care tests (POCTs) at rural antenatal health facilities (dispensaries) has the potential to improve access and timely treatment. Fundamental to the adoption of and adherence to new diagnostic approaches are healthcare workers’ and pregnant women’s (end-users) buy-in. A qualitative approach was used to capture end-users’ experiences of using POCTs for HIV, syphilis, malaria and anaemia to assess the appropriateness, acceptability and feasibility of integrated testing for ANC. Methods Seven dispensaries were purposively selected to implement integrated point-of-care testing for eight months in western Kenya. Semi-structured interviews were conducted with 18 healthcare workers (14 nurses, one clinical officer, two HIV testing counsellors, and one laboratory technician) who were trained, had experience doing integrated point-of-care testing, and were still working at the facilities 8–12 months after the intervention began. The interviews explored acceptability and relevance of POCTs to ANC, challenges with testing, training and supervision, and healthcare workers’ perspectives of client experiences. Twelve focus group discussions with 118 pregnant women who had attended a first ANC visit at the study facilities during the intervention were conducted to explore their knowledge of HIV, syphilis, malaria, and anaemia, experience of ANC point-of-care testing services, treatments received, relationships with healthcare workers, and experience of talking to partners about HIV and syphilis results. Results Healthcare workers reported that they enjoyed gaining new skills, were enthusiastic about using POCTs, and found them easy to use and appropriate to their practice. Initial concerns that performing additional testing would increase their workload in an already strained environment were resolved with experience and proficiency with the testing procedures. However, despite having the diagnostic tools, general health system challenges such as high client to healthcare worker volume ratio, stock-outs and poor working conditions challenged the delivery of adequate counselling and management of the four conditions. Pregnant women appreciated POCTs, but reported poor healthcare worker attitudes, drug stock-outs, and fear of HIV disclosure to their partners as shortcomings to their ANC experience in general. Conclusion This study provides insights on the acceptability, appropriateness, and feasibility of integrating POCTs into ANC services among end-users. While the innovation was desired and perceived as beneficial, future scale-up efforts would need to address health system weaknesses if integrated testing and subsequent effective management of the four conditions are to be achieved. Electronic supplementary material The online version of this article (10.1186/s12913-018-3844-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicole Young
- Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Florence Achieng
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Meghna Desai
- Division of Parasitic Diseases and Malaria and Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Jenny Hill
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - George Aol
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Godfrey Bigogo
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Kayla Laserson
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
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19
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Uptake of Home-Based Syphilis and Human Immunodeficiency Virus Testing Among Male Partners of Pregnant Women in Western Kenya. Sex Transm Dis 2018; 44:533-538. [PMID: 28809770 DOI: 10.1097/olq.0000000000000649] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Few men are tested for syphilis or human immunodeficiency virus (HIV) during their partner's pregnancy, a high-risk period for HIV and syphilis transmission. Offering home-based rapid testing of syphilis to couples during pregnancy can support prevention efforts to reduce transmission of sexually transmitted diseases and adverse pregnancy outcomes. METHODS We assessed men's uptake of paired (separate tests, single blood draw) point-of-care syphilis and HIV tests within a randomized controlled trial of pregnant women who received clinic or home partner HIV testing. We evaluated acceptance of paired HIV-syphilis testing during pregnancy or at 6 months postpartum, and evaluated whether addition of syphilis testing affected the uptake of HIV testing among men. RESULTS Of 601 women, we were unable to meet 101 male partners, and 180 tested before syphilis tests were available. Paired syphilis and HIV testing was offered at home to 80 men during pregnancy and to 230 men postpartum. For syphilis, 93% of men agreed to test during pregnancy and 98% agreed postpartum. For paired syphilis and HIV testing, 91% of men tested for both during pregnancy and 96% tested postpartum. Before syphilis test introduction, 96% of men accepted HIV testing, compared with 95% of men who accepted HIV testing when paired testing was offered. CONCLUSIONS Uptake of syphilis and HIV testing was high among male partners offered couple testing at home. Introducing syphilis testing did not adversely affect HIV testing among men. Point-of-care diagnostics outside facilities can increase testing of male partners who rarely accompany women to antenatal clinics.
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Peeling RW, Mabey D. Celebrating the decline in syphilis in pregnancy: a sobering reminder of what's left to do. LANCET GLOBAL HEALTH 2018; 4:e503-4. [PMID: 27443768 DOI: 10.1016/s2214-109x(16)30154-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 07/01/2016] [Indexed: 11/29/2022]
Affiliation(s)
| | - David Mabey
- London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK
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Adeyinka DA, Olakunde BO, Ozigbu CE, Agogo EA, Morka M, Atoba T, Obanubi C, Okorie G, Davies A, Oladimeji O. Elimination of mother-to-child transmission of syphilis: Is it a reality in Nigeria by 2020? Scand J Public Health 2017; 46:794-797. [DOI: 10.1177/1403494817744988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Congenital syphilis is a global health problem, yet it has received little attention in recent years. Despite cost-effective syphilis screening and treatment, it continues to contribute hugely to perinatal morbidity and mortality worldwide. Aims: To determine the prevalence and treatment coverage trend for syphilis among pregnant women in the national prevention of mother-to-child transmission programme in Nigeria and to evaluate progress towards the elimination of congenital syphilis in the country. Methods: A retrospective analysis of validated national health sector performance data on pregnant women attending antenatal care at prevention of mother-to-child transmission clinics from 2013 to 2016 in Nigeria. Results: The proportion of new antenatal care attendees who annually received serological testing for syphilis increased from 12.2% in 2013 to 16.3% in 2016 (p-trend<0.0001). Although the prevalence of maternal syphilis decreased from 3.2% in 2013 to 1.4% in 2016 (p-trend<0.0001), the syphilis treatment coverage during pregnancy has decreased from 71.3% in 2013 to 54.9% in 2016 (p-trend<0.0001). Conclusions: Maternal syphilis screening and treatment in Nigeria are inadequate to meet the elimination aspirations. A rapid scale-up of antenatal care syphilis screening and treatment are crucial to averting an epidemic in Nigeria by 2020.
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Affiliation(s)
- Daniel A. Adeyinka
- National AIDS & STIs Control Programme, Department of Public Health, Federal Ministry of Health, Nigeria
| | | | - Chamberline E. Ozigbu
- National AIDS & STIs Control Programme, Department of Public Health, Federal Ministry of Health, Nigeria
- University of South Carolina, Columbia, USA
| | - Emmanuel A. Agogo
- National Agency for Control of AIDS, Nigeria
- Nigeria Centre for Disease Control, Nigeria
| | - Mercy Morka
- National AIDS & STIs Control Programme, Department of Public Health, Federal Ministry of Health, Nigeria
| | - Temitope Atoba
- Department of Pediatrics, University College Hospital, Nigeria
| | | | | | | | - Olanrewaju Oladimeji
- Department of Public Health Medicine, College of Health Science, University of Kwazulu-natal, South Africa
- Centre for Community Health Care, Research and Development, Nigeria
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Abstract
Treponema pallidum subspecies pallidum (T. pallidum) causes syphilis via sexual exposure or via vertical transmission during pregnancy. T. pallidum is renowned for its invasiveness and immune-evasiveness; its clinical manifestations result from local inflammatory responses to replicating spirochaetes and often imitate those of other diseases. The spirochaete has a long latent period during which individuals have no signs or symptoms but can remain infectious. Despite the availability of simple diagnostic tests and the effectiveness of treatment with a single dose of long-acting penicillin, syphilis is re-emerging as a global public health problem, particularly among men who have sex with men (MSM) in high-income and middle-income countries. Syphilis also causes several hundred thousand stillbirths and neonatal deaths every year in developing nations. Although several low-income countries have achieved WHO targets for the elimination of congenital syphilis, an alarming increase in the prevalence of syphilis in HIV-infected MSM serves as a strong reminder of the tenacity of T. pallidum as a pathogen. Strong advocacy and community involvement are needed to ensure that syphilis is given a high priority on the global health agenda. More investment is needed in research on the interaction between HIV and syphilis in MSM as well as into improved diagnostics, a better test of cure, intensified public health measures and, ultimately, a vaccine.
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Affiliation(s)
- Rosanna W Peeling
- London School of Hygiene &Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - David Mabey
- London School of Hygiene &Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Mary L Kamb
- Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Xiang-Sheng Chen
- National Center for STD Control, Chinese Academy of Medical Sciences and Peking Union Medical College Institute of Dermatology, Nanjing, China
| | - Justin D Radolf
- Department of Medicine, UConn Health, Farmington, Connecticut, USA
| | - Adele S Benzaken
- Department of Surveillance, Prevention and Control of STI, HIV/AIDS and Viral Hepatitis, Ministry of Health, Brasília, Brazil
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[Educating health workers is key in congenital syphilis elimination in Colombia]. BIOMEDICA 2017; 37:416-424. [PMID: 28968019 DOI: 10.7705/biomedica.v37i3.3397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 11/21/2016] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Colombia promotes the diagnosis and treatment of gestational syphilis in a single visit using rapid diagnostic tests to prevent mother-to-child transmission. Additionally, integrated health programs pursue the coordinated prevention of mother-to-child transmission of syphilis/HIV. OBJECTIVE To identify knowledge gaps among health workers in the prevention of mother-to-child transmission of syphilis/HIV and to provide recommendations to support these programs. MATERIALS AND METHODS We conducted a descriptive study based on 306 surveys of health workers in 39 health institutions in the city of Cali. Surveys inquired about planning, management and implementation of services for pregnant women, clinical knowledge of HIV/syphilis rapid diagnostic tests, and prior training. RESULTS Knowledge deficits in the management of gestational syphilis were detected among the surveyed health workers, including physicians. Rapid tests for syphilis are currently used in clinical laboratories in Cali, however, procedural deficiencies were observed in their use, including quality control assurance. During the two years prior to the survey, training of health workers in the prevention of mother-to-child transmission of syphilis/HIV had been limited. Health workers are interested in identifying and treating gestational syphilis in a single event, in using rapid diagnostic tests and in receiving training. CONCLUSIONS Intensive training targeting health workers, policy/decision makers and academic groups is needed to ensure adequate implementation of new strategies for the prevention of mother-to-child transmission of syphilis/HIV.
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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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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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Abstract
In industrialized countries, the incidence of syphilis has decreased dramatically since the discovery of penicillin in the 1940s. However, syphilis and congenital syphilis are far from eradicated, especially in low- and middle-income countries. Syphilis in pregnant women is a cause of adverse pregnancy outcomes that can be prevented by screening for syphilis and early treatment in pregnancy. Several studies have found screening of pregnant women for syphilis to be a highly cost-effective intervention, even if the prevalence of syphilis is low. Obstacles to universal screening of pregnant women include low awareness of syphilis and low quality of antenatal care and healthcare in general in many low- and middle-income countries. For these settings, we need simpler and more reliable serological tests for syphilis, but we also need to strengthen health services in general to ensure sustainable antenatal care services to ensure sustainability of syphilis screening programmes.
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Affiliation(s)
- Anne Buvé
- Institute of Tropical Medicine, Nationalestraat 155, B-2000 Antwerp, Begium, Tel.: + 32 3247 6533; Fax: + 32 3247 6532
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Vermund SH. Screening for Sexually Transmitted Infections in Antenatal Care Is Especially Important Among HIV-Infected Women. Sex Transm Dis 2016; 42:566-8. [PMID: 26372928 DOI: 10.1097/olq.0000000000000342] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Sten H Vermund
- From the Vanderbilt Institute for Global Health and Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
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Estimating the Public Health Burden Associated With Adverse Pregnancy Outcomes Resulting From Syphilis Infection Across 43 Countries in Sub-Saharan Africa. Sex Transm Dis 2016. [PMID: 26222749 DOI: 10.1097/olq.0000000000000291] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Untreated syphilis in pregnancy is associated with adverse clinical outcomes to the infant. The study aimed to estimate the public health burden resulting from adverse pregnancy outcomes due to syphilis infection among pregnant women not screened for syphilis in 43 countries in sub-Saharan Africa. METHODS Estimated country-specific incidence of syphilis was generated from annual number of live births, the proportion of women with at least 1 antenatal care (ANC) visit, the syphilis prevalence rate, and the proportion of women screened for syphilis during ANC.Adverse pregnancy outcome data (stillbirth, neonatal death, low birth weight, and congenital syphilis) were obtained from published sources. Disability-adjusted life-year (DALY) estimates were calculated using undiscounted local life expectancy, the neonatal standard loss function, and relevant disability weights. The model assessed the potential impact of raising ANC coverage to at least 95% and syphilis screening to at least 95% (World Health Organization targets). RESULTS For all 43 sub-Saharan Africa countries, the estimated incidence of adverse pregnancy outcomes was 205,901 (95% confidence interval [CI], 113,256-383,051) per year, including stillbirth (88,376 [95% CI, 60,854-121,713]), neonatal death (34,959 [95% CI, 23,330-50,076]), low birth weight (22,483 [95% CI, 0-98,847]), and congenital syphilis (60,084 [95% CI, 29,073-112,414]), resulting in approximately 12.5 million DALYs. Countries with the greatest burden are (in DALYs, millions) Democratic Republic of the Congo (1.809), Nigeria (1.598), Ethiopia (1.466), and Tanzania (0.961). Attaining World Health Organization targets could reduce the burden by 8.5 million DALYs. CONCLUSIONS Substantial infant mortality and morbidity results from maternal syphilis infection concentrated in countries with low access to ANC or low rates of syphilis screening.
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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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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: 12] [Impact Index Per Article: 1.5] [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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Affiliation(s)
- Godfrey JA Walker
- The University of Liverpool; C/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health; First Floor, Liverpool Women's NHS Foundation Trust Crown Street Liverpool UK L8 7SS
| | - Damian Walker
- Bill & Melinda Gates Foundation; Cost-Effectiveness, Integrated Delivery, Global Development; Seattle USA WA 98102
| | - Daniel Molano Franco
- Fundacion Universitaria de Ciencias de la Salud, Hospital de San Jose, Clinica universitaria Colombia UNISANITAS; Department of Critical Care; Carrera 19 # 8-32 Bogota Bogota Colombia 11001
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Heazell AEP, Siassakos D, Blencowe H, Burden C, Bhutta ZA, Cacciatore J, Dang N, Das J, Flenady V, Gold KJ, Mensah OK, Millum J, Nuzum D, O'Donoghue K, Redshaw M, Rizvi A, Roberts T, Toyin Saraki HE, Storey C, Wojcieszek AM, Downe S. Stillbirths: economic and psychosocial consequences. Lancet 2016; 387:604-616. [PMID: 26794073 DOI: 10.1016/s0140-6736(15)00836-3] [Citation(s) in RCA: 359] [Impact Index Per Article: 44.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Despite the frequency of stillbirths, the subsequent implications are overlooked and underappreciated. We present findings from comprehensive, systematic literature reviews, and new analyses of published and unpublished data, to establish the effect of stillbirth on parents, families, health-care providers, and societies worldwide. Data for direct costs of this event are sparse but suggest that a stillbirth needs more resources than a livebirth, both in the perinatal period and in additional surveillance during subsequent pregnancies. Indirect and intangible costs of stillbirth are extensive and are usually met by families alone. This issue is particularly onerous for those with few resources. Negative effects, particularly on parental mental health, might be moderated by empathic attitudes of care providers and tailored interventions. The value of the baby, as well as the associated costs for parents, families, care providers, communities, and society, should be considered to prevent stillbirths and reduce associated morbidity.
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Affiliation(s)
- Alexander E P Heazell
- Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK; St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; International Stillbirth Alliance, New York, NY, USA.
| | - Dimitrios Siassakos
- International Stillbirth Alliance, New York, NY, USA; Academic Centre for Women's Health, University of Bristol, Bristol, UK; Southmead Hospital, Bristol, UK
| | - Hannah Blencowe
- Centre for Maternal Reproductive and Child Health, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Christy Burden
- Academic Centre for Women's Health, University of Bristol, Bristol, UK; Southmead Hospital, Bristol, UK
| | - Zulfiqar A Bhutta
- Center for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada; Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Nghia Dang
- Institute for Reproductive and Family Health, Hanoi Vinmec International General Hospital, Hanoi, Vietnam
| | - Jai Das
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Vicki Flenady
- International Stillbirth Alliance, New York, NY, USA; Mater Research Institute, University of Queensland, Brisbane, QLD, Australia
| | - Katherine J Gold
- International Stillbirth Alliance, New York, NY, USA; Department of Family Medicine and Department of Obstetrics, University of Michigan, Ann Arbor, MI, USA
| | | | - Joseph Millum
- Clinical Center Department of Bioethics, Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Daniel Nuzum
- Department of Obstetrics and Gynaecology, University College Cork, Cork University Maternity Hospital, Cork, Ireland
| | - Keelin O'Donoghue
- Department of Obstetrics and Gynaecology, University College Cork, Cork University Maternity Hospital, Cork, Ireland
| | - Maggie Redshaw
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Arjumand Rizvi
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Tracy Roberts
- Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | | | - Claire Storey
- International Stillbirth Alliance, New York, NY, USA
| | - Aleena M Wojcieszek
- International Stillbirth Alliance, New York, NY, USA; Mater Research Institute, University of Queensland, Brisbane, QLD, Australia
| | - Soo Downe
- ReaCH group, University of Central Lancashire, Preston, UK
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Abstract
Estimates of the burden of disease assess the mortality and morbidity that affect a population by producing summary measures of health such as quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs). These measures typically do not include stillbirths (fetal deaths occurring during the later stages of pregnancy or during labor) among the negative health outcomes they count. Priority-setting decisions that rely on these measures are therefore likely to place little value on preventing the more than three million stillbirths that occur annually worldwide. In contrast, neonatal deaths, which occur in comparable numbers, have a substantial impact on burden of disease estimates and are commonly seen as a pressing health concern. In this article we argue in favor of incorporating unintended fetal deaths that occur late in pregnancy into estimates of the burden of disease. Our argument is based on the similarity between late-term fetuses and newborn infants and the assumption that protecting newborns is important. We respond to four objections to counting stillbirths: (1) that fetuses are not yet part of the population and so their deaths should not be included in measures of population health; (2) that valuing the prevention of stillbirths will undermine women's reproductive rights; (3) that including stillbirths implies that miscarriages (fetal deaths early in pregnancy) should also be included; and (4) that birth itself is in fact ethically significant. We conclude that our proposal is ethically preferable to current practice and, if adopted, is likely to lead to improved decisions about health spending.
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Bocoum FY, Ouédraogo H, Tarnagda G, Kiba A, Tiendrebeogo S, Bationo F, Liestman B, Diagbouga S, Zarowsky C, Traoré RO, Kouanda S. Evaluation of the diagnostic performance and operational characteristics of four rapid immunochromatographic syphilis tests in Burkina Faso. Afr Health Sci 2015; 15:360-7. [PMID: 26124780 DOI: 10.4314/ahs.v15i2.8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Little information is available on the rapid diagnostic testing for syphilis in Burkina Faso. The objectives of the study were (i) to assess the sensitivity and specificity of four on site rapid tests in comparison with Treponema pallidum haemagglutination assay (TPHA) as a gold standard and (ii) to evaluate the operational characteristics of those tests among health workers in a maternity unit. METHODS Four rapid syphilis tests commercially available in Burkina Faso were evaluated using archived serum samples and Treponema pallidum hemagglutination assay (TPHA) as the gold standard. Blood samples were collected between November 2011 and June 2012 from blood donors at the Regional Blood Transfusion Center of Ouagadougou. The sensitivity and specificity of the tests were calculated. Evaluation of operational characteristics such as clarity of pamphlet, complexity of technique, duration, was conducted in a first-level healthcare center with health workers in maternity unit. RESULTS Alere DetermineTM Syphilis was the most sensitive of the four rapid syphilis tests evaluated. It was followed by SD Bioline Syphilis 3.0, Cypress Diagnostics Syphilis Quick test and Accu-Tell ® Rapid Anti-TP, which was the least sensitive. The four tests demonstrated a good diagnostic specificity for syphilis (95-98%), and healthcare workers found them easy to use. CONCLUSIONS The study allowed confirming the good performance of three of four rapid syphilis tests in Burkina Faso. More research will be conducted to assess the feasibility of introducing selected rapid tests for syphilis in antenatal care services.
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Affiliation(s)
- Fadima Yaya Bocoum
- Institut de Recherche en Science de la Santé (IRSS), Département biomédical et santé publique, Ouagadougou, Burkina Faso ; Free Afrik, Ouagadougou, Burkina Faso ; University of Western Cape, School of Public Health, Cape Town, South Africa
| | - Henri Ouédraogo
- Institut de Recherche en Science de la Santé (IRSS), Département biomédical et santé publique, Ouagadougou, Burkina Faso
| | - Grissoum Tarnagda
- Institut de Recherche en Science de la Santé (IRSS), Département biomédical et santé publique, Ouagadougou, Burkina Faso
| | - Alice Kiba
- Centre Régional de Transfusion Sanguine (CRTS), Ouagadougou, Burkina Faso
| | - Simon Tiendrebeogo
- Institut de Recherche en Science de la Santé (IRSS), Département biomédical et santé publique, Ouagadougou, Burkina Faso
| | - Fabrice Bationo
- Institut de Recherche en Science de la Santé (IRSS), Département biomédical et santé publique, Ouagadougou, Burkina Faso
| | | | - Serge Diagbouga
- Institut de Recherche en Science de la Santé (IRSS), Département biomédical et santé publique, Ouagadougou, Burkina Faso
| | - Christina Zarowsky
- University of Western Cape, School of Public Health, Cape Town, South Africa
| | | | - Séni Kouanda
- Institut de Recherche en Science de la Santé (IRSS), Département biomédical et santé publique, Ouagadougou, Burkina Faso
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Ansbro ÉM, Gill MM, Reynolds J, Shelley KD, Strasser S, Sripipatana T, Ncube AT, Tembo Mumba G, Terris-Prestholt F, Peeling RW, Mabey D. Introduction of Syphilis Point-of-Care Tests, from Pilot Study to National Programme Implementation in Zambia: A Qualitative Study of Healthcare Workers' Perspectives on Testing, Training and Quality Assurance. PLoS One 2015; 10:e0127728. [PMID: 26030741 PMCID: PMC4452097 DOI: 10.1371/journal.pone.0127728] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 04/20/2015] [Indexed: 11/18/2022] Open
Abstract
Syphilis affects 1.4 million pregnant women globally each year. Maternal syphilis causes congenital syphilis in over half of affected pregnancies, leading to early foetal loss, pregnancy complications, stillbirth and neonatal death. Syphilis is under-diagnosed in pregnant women. Point-of-care rapid syphilis tests (RST) allow for same-day treatment and address logistical barriers to testing encountered with standard Rapid Plasma Reagin testing. Recent literature emphasises successful introduction of new health technologies requires healthcare worker (HCW) acceptance, effective training, quality monitoring and robust health systems. Following a successful pilot, the Zambian Ministry of Health (MoH) adopted RST into policy, integrating them into prevention of mother-to-child transmission of HIV clinics in four underserved Zambian districts. We compare HCW experiences, including challenges encountered in scaling up from a highly supported NGO-led pilot to a large-scale MoH-led national programme. Questionnaires were administered through structured interviews of 16 HCWs in two pilot districts and 24 HCWs in two different rollout districts. Supplementary data were gathered via stakeholder interviews, clinic registers and supervisory visits. Using a conceptual framework adapted from health technology literature, we explored RST acceptance and usability. Quantitative data were analysed using descriptive statistics. Key themes in qualitative data were explored using template analysis. Overall, HCWs accepted RST as learnable, suitable, effective tools to improve antenatal services, which were usable in diverse clinical settings. Changes in training, supervision and quality monitoring models between pilot and rollout may have influenced rollout HCW acceptance and compromised testing quality. While quality monitoring was integrated into national policy and training, implementation was limited during rollout despite financial support and mentorship. We illustrate that new health technology pilot research can rapidly translate into policy change and scale-up. However, training, supervision and quality assurance models should be reviewed and strengthened as rollout of the Zambian RST programme continues.
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Affiliation(s)
- Éimhín M. Ansbro
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Michelle M. Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia, United States of America
| | - Joanna Reynolds
- Department of Social & Environmental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Katharine D. Shelley
- Department of Epidemiology and Biostatistics, George Washington University, Washington, District of Columbia, United States of America
| | - Susan Strasser
- Elizabeth Glaser Pediatric AIDS Foundation, Lusaka, Zambia
| | - Tabitha Sripipatana
- Office of Population and Reproductive Health, United States Agency for International Development, Washington, District of Columbia, United States of America
| | | | | | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rosanna W. Peeling
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Mabey
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Balira R, Mabey D, Weiss H, Ross DA, Changalucha J, Watson-Jones D. The need for further integration of services to prevent mother-to-child transmission of HIV and syphilis in Mwanza City, Tanzania. Int J Gynaecol Obstet 2015; 130 Suppl 1:S51-7. [PMID: 25963906 DOI: 10.1016/j.ijgo.2015.04.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the operational integration of maternal HIV testing and syphilis screening in Mwanza, Tanzania. METHODS Interviews were conducted with 76 health workers (HW) from three antenatal clinics (ANC) and three maternity wards in 2008-2009 and 1137 consecutive women admitted for delivery. Nine ANC health education sessions and client flow observations were observed. RESULTS Only 25.0% of HWs reported they had received training in both prevention of mother-to-child transmission (PMTCT) and syphilis screening. HIV and syphilis tests were sometimes performed in different rooms and results recorded in separate registers with different formats and the results were not always given by the same person. At delivery, most women had been tested for both HIV (79.4%) and syphilis (88.1%) during pregnancy. Of those not tested antenatally for each infection, 70.1% were tested for HIV at delivery but none for syphilis. CONCLUSION Integration of maternal HIV and syphilis screening was limited. Integrated care guidelines and related health worker training should address this gap.
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Affiliation(s)
- Rebecca Balira
- National Institute for Medical Research (NIMR), Mwanza, Tanzania.
| | - David Mabey
- London School of Hygiene and Tropical Medicine, London, UK
| | - Helen Weiss
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - David Anthony Ross
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - John Changalucha
- National Institute for Medical Research (NIMR), Mwanza, Tanzania
| | - Deborah Watson-Jones
- London School of Hygiene and Tropical Medicine, London, UK; Mwanza Intervention Trials Unit, NIMR, Mwanza, Tanzania
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Terris-Prestholt F, Vickerman P, Torres-Rueda S, Santesso N, Sweeney S, Mallma P, Shelley KD, Garcia PJ, Bronzan R, Gill MM, Broutet N, Wi T, Watts C, Mabey D, Peeling RW, Newman L. The cost-effectiveness of 10 antenatal syphilis screening and treatment approaches in Peru, Tanzania, and Zambia. Int J Gynaecol Obstet 2015; 130 Suppl 1:S73-80. [PMID: 25963907 PMCID: PMC4510253 DOI: 10.1016/j.ijgo.2015.04.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective Rapid plasma reagin (RPR) is frequently used to test women for maternal syphilis. Rapid syphilis immunochromatographic strip tests detecting only Treponema pallidum antibodies (single RSTs) or both treponemal and non-treponemal antibodies (dual RSTs) are now available. This study assessed the cost-effectiveness of algorithms using these tests to screen pregnant women. Methods Observed costs of maternal syphilis screening and treatment using clinic-based RPR and single RSTs in 20 clinics across Peru, Tanzania, and Zambia were used to model the cost-effectiveness of algorithms using combinations of RPR, single, and dual RSTs, and no and mass treatment. Sensitivity analyses determined drivers of key results. Results Although this analysis found screening using RPR to be relatively cheap, most (> 70%) true cases went untreated. Algorithms using single RSTs were the most cost-effective in all observed settings, followed by dual RSTs, which became the most cost-effective if dual RST costs were halved. Single test algorithms dominated most sequential testing algorithms, although sequential algorithms reduced overtreatment. Mass treatment was relatively cheap and effective in the absence of screening supplies, though treated many uninfected women. Conclusion This analysis highlights the advantages of introducing RSTs in three diverse settings. The results should be applicable to other similar settings.
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Affiliation(s)
| | - Peter Vickerman
- London School of Hygiene and Tropical Medicine, London, UK; University of Bristol, Bristol, UK
| | | | | | - Sedona Sweeney
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | - Rachel Bronzan
- Health and Development International, Newburyport, MA, USA
| | - Michelle M Gill
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | | | - Teodora Wi
- World Health Organization, Geneva, Switzerland
| | | | - David Mabey
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Lori Newman
- World Health Organization, Geneva, Switzerland
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Canadian Public Health Laboratory Network laboratory guidelines for the use of point-of-care tests for the diagnosis of syphilis in Canada. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2015; 26 Suppl A:29A-32A. [PMID: 25798163 PMCID: PMC4353982 DOI: 10.1155/2015/152039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Syphilis point-of-care tests (POCT) are widely available in developing countries enabling early diagnosis, treatment and support. The majority of commercially available tests use treponemal antigens and the presence of antibodies does not distinguish between current and past infection, which may lead to unnecessary antibiotic use and stigmatization of having a current STI. In hard-to-reach populations, the benefits may outweigh the risks. Available studies show reasonable performance of POCT with median sensitivity of 86%, specificity of 99% and positive predictive values >80% when prevalence was >0.3%. Although no syphilis POCT are approved in Canada at this time, a single study in an outreach setting in Alberta showed limited benefit due to a high prevalence of previous infection but more studies are needed. Newer dual tests employing treponemal and nontreponemal antigens look promising.
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Dassah ET, Adu-Sarkodie Y, Mayaud P. Factors associated with failure to screen for syphilis during antenatal care in Ghana: a case control study. BMC Infect Dis 2015; 15:125. [PMID: 25888254 PMCID: PMC4364573 DOI: 10.1186/s12879-015-0868-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Accepted: 03/04/2015] [Indexed: 11/22/2022] Open
Abstract
Background There is little data regarding the effect of ramping up new screening interventions on their uptake by target populations into routine care services in developing countries. This study aimed to determine patient-level factors associated with failure of pregnant women to get screened for syphilis during antenatal care, in the context of a national rollout of rapid syphilis point of care tests (POCTs) in Ghana. Methods An unmatched 1:2 case control study conducted among women admitted for delivery in two district hospitals in the Ashanti Region of Ghana from August to October 2010, 7 to 9 months after the introduction of POCTs in the region. Cases were women who had not been screened for syphilis during antenatal care and controls were women who had been screened. Patient-reported factors for being unscreened were examined using logistic regression to obtain odds ratios (ORs) and 95% confidence intervals (CIs). Results 160 consecutive unscreened and 327 screened women were recruited. Most women had good knowledge of syphilis (58.7% among unscreened women vs. 64.2% among screened; P = 0.24). Factors associated with failure to get screened were: attending antenatal care in a private health facility (adjusted OR, 11.09; 95% CI 5.48-22.48), previous adverse pregnancy outcome (adjusted OR, 1.98; 95% CI 1.22-3.23) and not being screened for HIV during the current pregnancy (adjusted OR, 2.78; 95% CI 1.50-5.13). The odds of being unscreened also increased with decreasing doses of intermittent preventive treatment for malaria in pregnancy received (P trend < 0.001) and decreasing education level (P trend = 0.02). Conclusion Significant risk factors for not being screened, following the national rollout of syphilis POCTs, related to the type of health facility where antenatal care was received and some of the women’s personal characteristics. Targeting of private medical facilities to include syphilis POCTs and support other neglected public health interventions should be a priority.
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Affiliation(s)
- Edward Tieru Dassah
- Department of Obstetrics and Gynaecology, Komfo Anokye Teaching Hospital, P. O. Box KS 1934, Kumasi, Ghana. .,School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Yaw Adu-Sarkodie
- Department of Obstetrics and Gynaecology, Komfo Anokye Teaching Hospital, P. O. Box KS 1934, Kumasi, Ghana. .,School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
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Morshed MG, Singh AE. Recent trends in the serologic diagnosis of syphilis. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2015; 22:137-47. [PMID: 25428245 PMCID: PMC4308867 DOI: 10.1128/cvi.00681-14] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Complexities in the diagnosis of syphilis continue to challenge clinicians. While direct tests (e.g., microscopy or PCR) are helpful in early syphilis, the mainstay of diagnosis remains serologic tests. The traditional algorithm using a nontreponemal test (NTT) followed by a treponemal test (TT) remains the standard in many parts of the world. More recently, the ability to automate the TT has led to the increasingly widespread use of reverse algorithms using treponemal enzyme immunoassays (EIAs). Rapid, point-of-care TTs are in widespread use in developing countries because of low cost, ease of use, and reasonable performance. However, none of the current diagnostic algorithms are able to distinguish current from previously treated infections. In addition, the reversal of traditional syphilis algorithms has led to uncertainty in the clinical management of patients. The interpretation of syphilis tests is further complicated by the lack of a reliable gold standard for syphilis diagnostics, and the newer tests can result in false-positive reactions similar to those seen with older tests. Little progress has been made in the area of serologic diagnostics for congenital syphilis, which requires assessment of maternal treatment and serologic response as well as clinical and laboratory investigation of the neonate for appropriate management. The diagnosis of neurosyphilis continues to require the collection of cerebrospinal fluid for a combination of NTT and TT, and, while newer treponemal EIAs look promising, more studies are needed to confirm their utility. This article reviews current tests and discusses current controversies in syphilis diagnosis, with a focus on serologic tests.
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Affiliation(s)
- Muhammad G Morshed
- Department of Pathology & Laboratory Medicine, Faculty of Medicine, University of British Columbia, and BC Public Health Microbiology and Reference Laboratory, Provincial Health Services Authority, Vancouver, BC, Canada
| | - Ameeta E Singh
- Department of Medicine/Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada
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Prevention of group B streptococcal disease in the first 3 months of life: Would routine maternal immunization during pregnancy be cost-effective? Vaccine 2014; 32:4778-85. [DOI: 10.1016/j.vaccine.2014.06.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 05/14/2014] [Accepted: 06/02/2014] [Indexed: 11/24/2022]
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Qin J, Yang T, Xiao S, Tan H, Feng T, Fu H. Reported estimates of adverse pregnancy outcomes among women with and without syphilis: a systematic review and meta-analysis. PLoS One 2014; 9:e102203. [PMID: 25025232 PMCID: PMC4099012 DOI: 10.1371/journal.pone.0102203] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 06/13/2014] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND To estimate probability of adverse pregnancy outcomes (APOs) among women with and without syphilis through a systematic review of published literatures. METHODOLOGY/PRINCIPAL FINDINGS Chinese and English literatures were searched for studies assessing pregnancy outcomes in the presence of maternal syphilis through August 2013. The prevalence estimates were summarized and analyzed by meta-analysis. Fifty-four literatures involving 11398 syphilitic women and 43342 non-syphilitic women were included from 4187 records initially found. Among untreated mothers with syphilis, pooled estimates were 76.8% for all APOs, 36.0% for congenital syphilis, 23.2% for preterm, 23.4% for low birth weight, 26.4% for stillbirth or fetal loss, 14.9% for miscarriage and 16.2% for neonatal deaths. Among syphilitic mother receiving treatment only in the late trimester (>28 weeks), pooled estimates were 64.4% for APOs, 40.6% for congenital syphilis, 17.6% for preterm, 12.4% for low birth weight, and 21.3% for stillbirth or fetal loss. Among syphilitic mothers with high titers (≥1∶8), pooled estimates were 42.8% for all APOs, 25.8% for congenital syphilis, 15.1% for preterm, 9.4% for low birth weight, 14.6% for stillbirth or fetal loss and 16.0% for neonatal deaths. Among non-syphilitic mothers, the pooled estimates were 13.7% for all APOs, 7.2% for preterm birth, 4.5% for low birth weight, 3.7% for stillbirth or fetal loss, 2.3% for miscarriage and 2.0% for neonatal death. Begg's rank correlation test indicated little evidence of publication bias (P>0.10). Substantial heterogeneity was found across studies in the estimates of all adverse outcomes for both women with syphilis (I2 = 93.9%; P<0.0001) and women without syphilis (I2 = 94.8%; P<0.0001). CONCLUSIONS/SIGNIFICANCE Syphilis continues to be an important cause of substantial perinatal morbidity and mortality, which reminds that policy-makers charged with resource allocation that the elimination of mother-to-child transmission of syphilis is a public health priority.
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Affiliation(s)
- Jiabi Qin
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Hunan, China
| | - Tubao Yang
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Hunan, China
| | - Shuiyuan Xiao
- Department of Social Medicine, School of Public Health, Central South University, Hunan, China
| | - Hongzhuan Tan
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Hunan, China
| | - Tiejian Feng
- Department of Dermatology and Venereal Disease, Shenzhen Center for Chronic Disease Control and Prevention, Shenzhen, China
| | - Hanlin Fu
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Hunan, China
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Synthesized prevention and control of one decade for mother-to-child transmission of syphilis and determinants associated with congenital syphilis and adverse pregnancy outcomes in Shenzhen, South China. Eur J Clin Microbiol Infect Dis 2014; 33:2183-98. [PMID: 24973132 DOI: 10.1007/s10096-014-2186-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 06/10/2014] [Indexed: 10/25/2022]
Abstract
The purpose of this investigation was to assess the effectiveness of an intervention program on mother-to-child transmission (MTCT) of syphilis and investigate determinants of congenital syphilis (CS) and adverse pregnancy outcomes (APOs). The Shenzhen local government initiated an intervention program of MTCT of syphilis in 2001. Based on this program, maternal and paternal factors associated with CS and APOs among syphilitic women were investigated from 2007 to 2012 by a prospective cohort study. From 2002 to 2012, 2,441,237 pregnant women were screened and screening coverage reached 97.2 % in 2012. In the background of continuing growth of CS in China, CS in Shenzhen significantly decreased from 109.3 cases in 2002 to 9.9 cases in 2012 per 100,000 live births. Maternal education (adjusted odds ratio [aOR]CS = 0.65; aORAPOs = 0.79) and history of syphilis (aORCS = 0.28; aORAPOs = 0.61), as well as paternal age (aORCS = 0.62; aORAPOs = 0.86) and education (aORCS = 0.66; aORAPOs = 0.86) were negatively associated with CS and APOs, but maternal unmarried status (aORCS = 1.95; aORAPOs = 2.61), inadequate antenatal care (ANC) (aORCS = 3.61; aORAPOs = 1.79), more sexual partners (aORCS = 1.51; aORAPOs = 1.39), every week of delay in treatment (aORCS = 2.82; aORAPOs = 1.27), higher baseline titers of nontreponemal antibodies (aORCS = 5.65; aORAPOs = 1.47), early syphilis (aORCS = 23.24; aORAPOs = 26.95), and non-penicillin treatment (aORCS = 3.00; aORAPOs = 2.16), as well as paternal history of cocaine use (aORCS = 2.70; aORAPOs = 2.44) and positive (aORCS = 4.14; aORAPOs = 1.50) or unknown (aORCS = 2.37; aORAPOs = 2.06) status of syphilis increased the risk of CS and APOs. Condom use (aOR = 0.70) decreased MTCT of syphilis. A ten-year program consisting of screening and treatment, early ANC, health education, partners tracking, detection, and treatment, follow-up visits, and information management is an effective means to block MTCT of syphilis. Maternal and paternal factors constituted two separate profiles associated with MTCT of syphilis.
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Integration of preventing mother-to-child transmission of HIV and syphilis testing and treatment in antenatal care services in the Northern Cape and Gauteng provinces, South Africa. Sex Transm Dis 2014; 40:846-51. [PMID: 24113405 DOI: 10.1097/olq.0000000000000042] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND South Africa recommends universal syphilis and HIV testing in pregnancy, with prompt antiretroviral therapy or penicillin treatment for women testing positive. METHODS We used a multistage, purposeful sampling strategy to retrospectively identify clinical records from a sample (7.3%) of 32,518 women delivering from January 2005 to June 2006 at 6 public clinics in the Northern Cape and Gauteng. Descriptive analyses and logistic regression were used to assess coverage and factors related to testing and treatment of HIV and syphilis. RESULTS Of 2379 women sampled, 93% accessed antenatal care (ANC) services during pregnancy and 71% before the third pregnancy trimester. Testing during pregnancy or delivery was 74% for HIV and 84% for syphilis; testing at the first ANC visit was 41% and 71%; and infection prevalence at delivery was 14% and 5%, respectively. Of 243 women with reactive HIV tests, 104 (43%) had treatment documented (single-dose nevirapine) before delivery. Of 98 women with reactive syphilis tests, 73% had documented receipt of 1 penicillin injection and 36% had all 3 recommended injections. Multivariable analysis found women tested for syphilis were almost 4 times more likely to have had no HIV test compared with those without syphilis testing (adjusted odds ratios, 3.9; 95% confidence interval, 1.7-5.5). CONCLUSIONS Integration and provision of a package of HIV and syphilis testing at the first ANC visit and decentralizing treatments of both infections to primary care settings could increase the coverage of testing and treatment services, thus enhancing the effectiveness of current programs eliminating mother-to-child transmission of HIV and syphilis.
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Kahn JG, Jiwani A, Gomez GB, Hawkes SJ, Chesson HW, Broutet N, Kamb ML, Newman LM. The cost and cost-effectiveness of scaling up screening and treatment of syphilis in pregnancy: a model. PLoS One 2014; 9:e87510. [PMID: 24489931 PMCID: PMC3906198 DOI: 10.1371/journal.pone.0087510] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 12/25/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Syphilis in pregnancy imposes a significant global health and economic burden. More than half of cases result in serious adverse events, including infant mortality and infection. The annual global burden from mother-to-child transmission (MTCT) of syphilis is estimated at 3.6 million disability-adjusted life years (DALYs) and $309 million in medical costs. Syphilis screening and treatment is simple, effective, and affordable, yet, worldwide, most pregnant women do not receive these services. We assessed cost-effectiveness of scaling-up syphilis screening and treatment in existing antenatal care (ANC) programs in various programmatic, epidemiologic, and economic contexts. METHODS AND FINDINGS We modeled the cost, health impact, and cost-effectiveness of expanded syphilis screening and treatment in ANC, compared to current services, for 1,000,000 pregnancies per year over four years. We defined eight generic country scenarios by systematically varying three factors: current maternal syphilis testing and treatment coverage, syphilis prevalence in pregnant women, and the cost of healthcare. We calculated program and net costs, DALYs averted, and net costs per DALY averted over four years in each scenario. Program costs are estimated at $4,142,287 - $8,235,796 per million pregnant women (2010 USD). Net costs, adjusted for averted medical care and current services, range from net savings of $12,261,250 to net costs of $1,736,807. The program averts an estimated 5,754 - 93,484 DALYs, yielding net savings in four scenarios, and a cost per DALY averted of $24 - $111 in the four scenarios with net costs. Results were robust in sensitivity analyses. CONCLUSIONS Eliminating MTCT of syphilis through expanded screening and treatment in ANC is likely to be highly cost-effective by WHO-defined thresholds in a wide range of settings. Countries with high prevalence, low current service coverage, and high healthcare cost would benefit most. Future analyses can be tailored to countries using local epidemiologic and programmatic data.
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Affiliation(s)
- James G. Kahn
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco; Super Models for Global Health, Berkeley, California, United States of America
| | - Aliya Jiwani
- Super Models for Global Health, Arlington, Virginia, United States of America
| | - Gabriela B. Gomez
- Department of Global Health, Academic Medical Centre, University of Amsterdam and Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Sarah J. Hawkes
- UCL Institute for Global Health, University College London, London, United Kingdom
| | - Harrell W. Chesson
- Division of Sexually Transmitted Disease Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Nathalie Broutet
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Mary L. Kamb
- Division of Sexually Transmitted Disease Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Lori M. Newman
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Rapid-Testing Technology and Systems Improvement for the Elimination of Congenital Syphilis in Haiti: Overcoming the "Technology to Systems Gap". JOURNAL OF SEXUALLY TRANSMITTED DISEASES 2013; 2013:247901. [PMID: 26316955 PMCID: PMC4437433 DOI: 10.1155/2013/247901] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 11/03/2013] [Indexed: 11/25/2022]
Abstract
Background. Despite the availability of rapid diagnostic tests and inexpensive treatment for pregnant women, maternal-child syphilis transmission remains a leading cause of perinatal morbidity and mortality in developing countries. In Haiti, more than 3000 babies are born with congenital syphilis annually. Methods and Findings. From 2007 to 2011, we used a sequential time series, multi-intervention study design in fourteen clinics throughout Haiti to improve syphilis testing and treatment in pregnancy. The two primary interventions were the introduction of a rapid point-of-care syphilis test and systems strengthening based on quality improvement (QI) methods. Syphilis testing increased from 91.5% prediagnostic test to 95.9% after (P < 0.001) and further increased to 96.8% (P < 0.001) after the QI intervention. Despite high rates of testing across all time periods, syphilis treatment lagged behind and only increased from 70.3% to 74.7% after the introduction of rapid tests (P = 0.27), but it improved significantly from 70.2% to 84.3% (P < 0.001) after the systems strengthening QI intervention. Conclusion. Both point-of-care diagnostic testing and health systems-based quality improvement interventions can improve the delivery of specific evidence-based healthcare interventions to prevent congenital syphilis at scale in Haiti. Improved treatment rates for syphilis were seen only after the use of systems-based quality improvement approaches.
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Kay NS, Peeling RW, Mabey DC. State of the art syphilis diagnostics: rapid point-of-care tests. Expert Rev Anti Infect Ther 2013; 12:63-73. [PMID: 24308715 DOI: 10.1586/14787210.2014.860356] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Syphilis remains an important and entirely preventable cause of stillbirth and neonatal mortality. More than 1 million women with active syphilis become pregnant each year. Without treatment, 25% of them will deliver a stillborn baby, 33% will deliver a live 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. Until recently access to screening in low- and middle-income countries has been limited, since screening tests have been laboratory based, requiring equipment, electricity and trained laboratory staff. Now a number of rapid, cheap, simple and accurate screening tests are available and can give a result in 15-20 min, enabling those who require treatment to be treated at their first visit.
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Affiliation(s)
- Natasha S Kay
- St Mary's Hospital, Praed Street, W2 1NY, London, UK
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The Impact of Integration of Rapid Syphilis Testing during Routine Antenatal Services in Rural Kenya. JOURNAL OF SEXUALLY TRANSMITTED DISEASES 2013; 2013:674584. [PMID: 26316963 PMCID: PMC4437431 DOI: 10.1155/2013/674584] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 09/23/2013] [Indexed: 11/17/2022]
Abstract
We evaluated the integration of rapid syphilis tests (RSTs) and penicillin treatment kits into routine antenatal clinic (ANC) services in two rural districts in Nyanza Province, Kenya. In February 2011, nurses from 25 clinics were trained in using RSTs and documenting test results and treatment. During March 2011–February 2012, free RSTs and treatment kits were provided to clinics for use during ANC visits. We analyzed ANC registry data from eight clinics during the 12-month periods before and during RST program implementation and compared syphilis testing, diagnosis, and treatment during the two periods. Syphilis testing at first ANC visit increased from 18% (279 of 1,586 attendees) before the intervention to 70% (1,123 of 1,614 attendees) during the intervention (P < 0.001); 35 women (3%) tested positive during the intervention period compared with 1 (<1%) before (P < 0.001). Syphilis treatment was not recorded according to training recommendations; seven clinics identified 28 RST-positive women and recorded 34 treatment kits as used. Individual-level data from three high-volume clinics supported that the intervention did not negatively affect HIV test uptake. Integrating RSTs into rural ANC services increased syphilis testing and detection. Record keeping on treatment of syphilis in RST-positive women remains challenging.
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Kuznik A, Lamorde M, Nyabigambo A, Manabe YC. Antenatal syphilis screening using point-of-care testing in Sub-Saharan African countries: a cost-effectiveness analysis. PLoS Med 2013; 10:e1001545. [PMID: 24223524 PMCID: PMC3818163 DOI: 10.1371/journal.pmed.1001545] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Accepted: 09/16/2013] [Indexed: 11/29/2022] Open
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.
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Affiliation(s)
- Andreas Kuznik
- Infectious Diseases Institute, Makerere College of Health Sciences, Kampala, Uganda
- Pfizer, New York, New York, United States of America
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere College of Health Sciences, Kampala, Uganda
| | - Agnes Nyabigambo
- Infectious Diseases Institute, Makerere College of Health Sciences, Kampala, Uganda
| | - Yukari C. Manabe
- Infectious Diseases Institute, Makerere College of Health Sciences, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
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